J" 


y- 


/^  :^' 


/^   WE     \ 

SCIB3ICES 
UBRABV 


f^^-^^  y -^-/v 


OBSTETRICAL,  TABLE. 


267 


f.  •"  ■-  1    A  -/  * 

-■  a  S  "  ;u.  — 
to  Od  >.S§  3 
mS  ^=:  >,~'  li 
■~  =S  Oi'C  aj  n  > 

«i-     —  m  S'  >"  *ii-" 

«  c  o  E  s- a 

1' m  '^  hfSr  J 
c  *  g  c      ^^-^ 

c  ^  a;  *"  r  iJ  > 
■a     S     « & 

•n  P<>.i  C  "'=' 

o  t.  «■"  — .Z3 

.a  (B  ^  r-      -  0 

^  a)  N  o 

o  a  o  c3 

§!a;5i  to 
o  08 -a  1. 


t:  £  g  g  SB 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonscienc1889play 


\rE. 
..  .i 

er  of 
mer 

..CI! 


I( 


ing 
ig  P 
■ig  P 
ng  P.     I 

^'"l   f 
Z)er?f  * 

mo     r. 

ff'  .1 


LES, 


n  of 


L^ 


Co)u 


1  i^C-t'0-«-^-^ 


>--^^L^^^  a<^^-'''^'^'>^^  ^^^^.^c^-^^-z^^ 


A  TKEATISE 


THE  SCIENCE  AND  PRACTICE 


MIDWIFEEY, 


BY 

W.  S.  PLAYFAIR,  M,D.,  LL,D.,  F.R.C.P., 

physician-accoucheur' ;4'0  H.  I.  AND  R.  H.  THE  DUCHESS  OF  EDINBURGH  ;  PROFESSOR  OF  OBSTETRIC 
MEDICINE  IN   king's  COLLEGE;   PHYSICIAN  FOR  THE  DISEASES  OF   WOMEN  AND  CHILDREN  TO 
king's  COLLEGE  HOSPITAL;  CONSULTING   PHYSICIAN   TO  THE  GENERAL  LYING-IN   HOS- 
PITAL  AND    TO    THE    EVELINA    HOSPITAL  FOR  CHILDREN;    LATE    PRESIDENT 
OF    THE    OBSTETRICAL    SOCIETY    OF    lONDON  ;    EXAMINER  IN  MID- 
WIFERY   TO    THE    UNIVERSITY   OF  LONDON  AND  TO 
THE    ROYAL    COLLEGE    OF  PHYSICIANS. 


FIFTH  AMERICAN  FROM  THE  SEVENTH  ENGLISH  EDITION. 


WITH  NOTES  AND   ADDITIONS 


BY 

EGBERT   P.  HARRIS,  M.D. 


WITH  FIVE  PLATES  AND  TWO  HUNDRED  AND  SEVEN  ILLUSTRATIONS. 


PHILADELPHIA : 
LEA    BROTHERS    &    CO. 

1889. 


^6) 

/8Sf 


Entered  according  to  Act  of  Congress,  in  the  year  1889,  by 

LEA    BROTHERS   &   CO., 

in  the  OflBce  of  the  Librarian  of  Congress  at  Washington.     All  rights  reserved. 


Westcott  a  Thomson,  William  J.  Pornan, 

i'itereolypers  and  Eleclrotypers,  Philada.  Printer.  PliiUida. 


EDITOR'S  PREFACE 

TO   THE 

FIFTH  AMEEICAN  EDITIOK 


Four  years  have  passed  since  the  last  American  edition  was  issued, 
and  this  period  has  worked  a  revolution  in  the  results  attained  in  sev- 
eral forms  of  obstetric  surgery :  notably  is  this  the  case  in  the  Porro- 
Csesarean  operation ;  the  conservative  Csesareau  operation ;  and  the 
exsective  method  of  treating  extra-uterine  pregnancy  where  the  foetus 
is  alive  and  of  viable  development.  The  Porro  operation  has  fallen  in 
its  rate  of  mortality  since  1884  from  58  to  less  than  20  per  cent. ;  and 
the  Conservative  or  Improved  Csesarean,  from  45  per  cent,  to  a  general 
average  of  20  per  cent.,  and  for  Continental  Europe  of  12.  The 
exsective  operation  named  had  had  but  one  case  prior  to  1885,  but 
has  now  had  five  without  the  death  of  a  mother.  These  facts  are  not 
mentioned  in  the  last  English  edition.  Laparo-elytrotomy,  which  was 
attracting  considerable  attention  four  years  ago,  has  almost  ceased  to 
exist,  by  reason  of  the  diminished  death-rate  under  the  improved 
Csesarean  section,  which  in  Germany  has  been  one  case  lost  in  eight. 
Laparo-elytrotomy  has  therefore  not  been  performed  since  September 
18,  1887.  The  Editor  has  brought  up  the  work  to  date  upon  these 
subjects,  and  their  statistical  records  to  the  close  of  the  year  1888.  All 
of  the  American  additions,  except  the  article  upon  the  forceps,  have 
been  either  rewritten  or  remodelled,  and  many  new  and  short  notes 
have  been  added  where  required.  The  work  has  been  sufficiently 
Americanized,  upon  the  points  where  English  and  American  obstetri- 
cians differ  in  opinion  and  practice,  to  fit  it  for  the  uses  of  American 
medical  students  and  obstetricians.  All  notes  and  additions  have  been 
distinguished  by  enclosure  in  brackets  [  ]. 

329  South  12th  Street,  Philadelphia, 
July  11,  1SS9. 


AUTHOR'S  PREFACE 

TO   THE 

SEVENTH  ENGLISH  EDITION. 


The  Author  has  again  the  satisfaction  of  presenting  to  the  profes- 
sion a  new  edition  of  his  work.  Since  the  last  edition  has  been 
exhausted  in  about  two  years,  there  are  necessarily  not  many  changes 
to  make;  still,  the  whole  has  been  carefully  revised,  some  portions  have 
been  re-written,  and  several  new  illustrations  have  been  added.  The 
chief  change  in  this  edition,  however,  is  that  the  obstetric  nomenclature 
decided  on  by  a  committee  appointed  at  the  International  Medical  Con- 
gress, held  at  Washington  in  1887,  has  been  introduced.  This  com- 
mittee was  presided  over  by  Professor  A.  R.  Simpson  of  Edinburgh, 
and  there  can  be  little  doubt  that  its  recommendations  will  eventually 
be  generally  adopted,  and  will  lead  to  something  like  uniformity  in 
obstetric  description.  The  Author  has  hitherto  not  used  letters  in 
describing  the  various  cranial  positions  and  the  like,  chiefly  because  he 
personally  thought  them  rather  pedantic  and  not  necessarily  leading  to 
simplicity.  Now,  however,  that  so  authoritative  a  committee  has  pro- 
nounced in  their  favor,  and  that  there  is  a  reasonable  hope  of  the  same 
letters  being  employed  by  writers  in  various  countries,  he  has  thought 
it  advisable  to  introduce  them  in  brackets,  so  as  to  give  his  readers  the 
opportunity  of  familiarizing  themselves  with  their  use.  The  Author 
has  once  more  to  express  his  grateful  thanks  to  Dr.  W.  Tyrrell 
Brooks  of  Oxford,  to  his  colleague  Professor  Crookshank  of  King's 
College,  and  to  Dr.  John  Phillips,  for  their  valuable  assistance.  Dr. 
Brooks  has,  for  the  second  time,  revised  the  chapters  on  conception 
and  generation ;  Dr.  Crookshank  has  done  the  same  with  reference 
to  the  bacteriology  of  puerperal  septicaemia ;  and  Dr.  Phillips,  as  on 
several  previous  occasions,  has  spared  the  Author  much  labor  by  his 
aid  in  passing  the  work  through  the  press. 

31  George  Street,  Hanover  Square, 
January,  1SS9. 


PREFACE  TO  THE  FIRST  EDITION. 


Those  who  have  studied  the  progress  of  Midwifery  know  that  there 
is  no  department  of  medicine  in  which  more  has  been  done  of  late  years, 
and  none  in  which  modern  views  of  practice  differ  more  widely  from 
those  prevalent  only  a  short  time  ago.  The  Author's  object  has  been  to 
place  in  the  hands  of  his  readers  an  epitome  of  the  science  and  practice 
of  midwifery  which  embodies  all  recent  advances.  He  is  aware  that  on 
certain  important  points  he  has  recommended  practice  which  not  long 
ago  would  have  been  considered  heterodox  in  the  extreme,  and  which 
even  now  will  not  meet  with  general  approval.  He  has,  however,  the 
satisfaction  of  knowing  that  he  has  only  done*  so  after  very  deliberate 
reflection,  and  with  the  profound  conviction  that  such  changes  are  right 
and  that  they  will  stand  the  test  of  experience.  He  has  endeavored  to 
dwell  especially  on  the  practical  part  of  the  subject,  so  as  to  make  the 
work  a  useful  guide  in  this  most  anxious  and  responsible  branch  of  the 
profession.  It  is  admitted  by  all  that  emergencies  and  difficulties  arise 
more  often  in  this  than  in  any  other  branch  of  practice ;  and  there  is  no 
part  of  the  j)ractitioner's  work  which  requires  more  thorough  knowledge 
or  greater  experience.  It  is,  moreover,  a  lamentable  fact  that  students 
generally  leave  their  schools  more  ignorant  of  obstetrics  than  of  any 
other  subject.  So  long  as  the  absurd  regulations  exist  which  oblige  the 
lecturer  on  midwifery  to  attempt  the  impossible  task  of  teaching  obstet- 
rics in  a  short  three  months'  course — an  absurdity  M'hich  has  over  and 
over  again  been  pointed  out — such  must  of  necessity  be  the  case.  This 
must  be  the  Author's  excuse  for  dwelling  on  many  topics  at  greater 
length  than  some  will  doubtless  think  their  importance  merits,  since  he 
desires  to  place  in  the  hands  of  his  students  a  work  which  may  in  some 
measure  supply  the  inevitable  defects  of  his  lectures. 


viii  rilF.FACK    TO    TlIK   IIIIST   F.DITIOS. 

iNIaiiy  (if  tlif  illii-tratiiiiis  arc  cdpifd  Iroiii  ]ii'(\i(iii-  aiitliois,  while 
si>nu' arc  (iritiiiial.  'V\\v  lolKtwiii;^,' (jiinlatinii  rroiii  the  iirdiKv  to  Tyler 
Smith's  ManiKtl  of  Ohstdrirx  will  explain  w  liy  the  >(»iiree  (»j'  ilu-  copied 
wood-cuts  has  not  been  in  each  instance  acknowled<::ed  :  "  M'hen  I  lx.'gan 
to  jniljlish,  I  determined  to  <rivc  the  authority  for  every  wood-cut  co])ied 
from  other  works.  1  soon  f()und,  however,  that  obstetric  authors  of  all 
countries,  Ironi  the  time  of  Mauriceau  downward,  had  copied  each  other 
so  freely  without  acknowledgment  as  to  render  it  difficult  or  iinj)ossible 
to  trace  the  originals." 

The  Author  has  to  express  his  acknowledgments  to  many  friends  for 
their  kind  assistance  by  the  loan  of  illustrations  and  otherwise,  and  more 
especially  to  his  colleague,  Dr.  Hayes,  for  his  valuable  aid  in  passing 
the  work  through  the  press. 

31  George  Street,  Hanover  Square, 
March,  1876. 


CONTENTS. 


PART   I. 


ANATOMY   AND   PHYSIOLOGY   OF   THE    ORGANS    CONCERNED 
IN   PARTURITION. 


CHAPTEK    I. 

ANATOMY    OP    THE    PELVIS. 

PAGE 

Its  importance — Formation  of  Pelvis — The  os  innominatum ;  its  three  divisions 
— Separation  between  the  True  and  False  Pelvis — The  Sacrum  and  Coccyx — 
Mechanical  relations  of  the  Sacrum — Pelvic  articulations  and  ligaments — 
Movements  of  the  Pelvic  Joints — The  Pelvis  as  a  whole — Difierences  in  the 
two  sexes — Measurements  of  the  Pelvis — Its  diameters,  planes,  and  axes — 
Development  of  the  Pelvis  —Soft  parts  in  connection  with  the  Pelvis  ....      33 

CHAPTER    II. 

THE  FEMALE  GENERATIVE  ORGANS. 

Division  according  to  Function  :  1.  External  or  Copulative  ;  2.  Internal  or  Forma- 
tive Organs — Mons  Veneris — Labia  majora  and  minora — The  Clitoris — ^The 
Vestibule  and  Orifice  of  Urethra — Passing  of  the  female  catheter — Orifice  of 
Vagina — The  Hymen — The  glands  of  the  Vulva — The  Perineum — The  Va- 
gina— The  Uterus  :  its  position  and  anatomy — [Partitioned  Uterus] — The 
ligaments  of  the  Uterus — The  Parovarium — Tlie  Fallopian  Tubes — The 
Ovaries — The  Graafian  Follicles  and  the  Ova — The  Mammary  Glands   .    .      49 

CHAPTER    III. 

OVULATION    AND    MENSTRUATION. 

Functions  of  the  Ovary — Changes  in  the  Graafian  Follicle :  1.  Maturation ;  2.  Es- 
cape of  the  Ovum — Formation  of  the  Cor^jus  Luteum — [Precocious  Physical 
Womanhood] — Quality  and  source  of  the  Menstrual  blood— Theory  of  Men- 
struation— Purpose  of  the  Menstrual  loss — A'icarious  Menstruation — Cessation 
of  Menstruation 81 


PART  II. 

PllEGXANCY 


CIIAITKK    1. 
CONCEPTION    AND   GENERATION. 

PAGE 

The  Semen — Site  and  mode  of  Impregnation — Clianges  in  tiie  Ovum — Cleavage 
of  the  Yelk — Tlie  Decidiia  and  its  ibrniation — Formation  of  the  Anniion — 
Tlie  Umbilical  Vesicle  and  Allantois — The  Liquor  Amnii  and  its  uses — Tlie 
Chorion — The  Placenta;  its  formation,  anatomy,  and  functions 95 

CHAPTER    II. 

THE    ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS. 

Appearance  of  the  Foetus  at  various  stages  of  development — [Very  Small  Foetuses 
hal)itually  produced  by  some  mothers] — Anatomy  of  the  Fcetal  Head — The 
Sutures  and  Fontanelles — Influence  of  Sex  and  Race  on  the  Fcetal  Head — 
Position  of  the  Foetus  in  utero — Functions  of  the  Foetus — The  Fo-tal  Circula- 
tion  121 

CHAPTER    III. 

PREGNANCY. 

Changes  in  the  form  and  dimensions  of  the  Uterus — Changes  in  the  Cervix — 
Changes  in  the  texture  of  the  Uterine  Tissues,  the  Peritoneal,  Muscular,  and 
Mucous  Coats — General  modifications  in  the  Body  produced  by  Pregnancy    .     136 

CHAPTER    IV. 

SIGNS    AND   SY'MPTOMS    OF    PREGNANCY. 

Signs  of  a  fruitful  Conception — Cesssition  of  Menstruation — [Double  uterus,  one- 
half  pregnant,  the  other  Menstruating] — Sympathetic  Disturbances — Morning 
Sickness,  etc. — Mammary  Changes — Enlargement  of  the  Abdomen — (Quicken- 
ing— Intermittent  Uterine  Contractions — [Intermittent  uterine  contractions  of 
Pregnancy  sometimes  painful] — Vaginal  signs  of  Pregnancy — Ballottement, 
etc. — Auscultatory  Signs  of  Pregnancy — Fa'tal  Pulsations — Uterine  Souffle,  etc.  147 

CHAPTER    V. 

THE    DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY —  SPURIOUS     PREGNANCY-TIIE 
DURATION    OF    PREGNANCY— SIGNS   OF   RECENT   PREGNANCY. 

Adipo.se  enlargement  of  the  Abdomen — Distension  of  the  Uterus  by  retained 
Men.ses,  etc. — Congestive  enlargement  of  Uterus — A.scites — Uterine  and  Ova- 
rian Tumoi-s — Spurious  Pregnancy  ;  its  Causes,  Symptoms,  and  Diagnosis — The 
Duration  of  Pregnancy — Sources  of  Fallacy — Methods  of  predicting  Date  of 
Delivery — Protraction  of  Pregnancy — Signs  of  recent  Delivery I'*}! 


CONTENTS.  xi 

CHAPTER    VI. 

ABNORMAL    PREGNANCY,    INCLUDING    MULTIPLE    PREGNANCY,   SUPERFCETATION, 
EXTRA-UTERINE    FCETATION,    AND    MISSED    LABOR. 

PAGE 

Plural  Births;  their  Frequency,  relative  Frequency  in  different  Countries,  Causes, 
etc. — Superfoetation  and  Snperfecundation — Nature — Explanation — Objec- 
tions to  admission  of  such  cases — Their  [)ossibility  admitted — Extra-uterine 
Pregnancy — Classification — Causes — Tubal  Pregnancies — Changes  in  the  Fal- 
lopian Tubes — Condition  of  Uterus — Pi-ogress  and  Termination — Diagnosis — 
Treatment — [Extra-uterine  pregnancy] — [Toxic  injections  in  extra-uterine 
pregnancy  dangerous]  —  Abdominal  Pregnancy ;  Description,  Diagnosis, 
Treatment — [Exsection  of  cyst  and  placenta  after  removal  of  a  living  and 
viable  Foetus  in  extra-uterine  pregnancy] — Missed  Labor;  its  Symptoms, 
Causes,  and  Treatment — [Causes  of  Missed  Labor] 170 


CHAPTER    VII. 

DISEASES    OF    PREGNANCY. 

Some  only  Sympathetic,  others  Mechanical  or  Complex  in  their  Origin — Derange- 
ments of  the  Digestive  Organs ;  Excessive  Nausea  and  Vomiting,  Diarrhcea, 
Constipation,  Hemorrhoids,  Ptyalism,  etc. — [Cough  of  pregnancy]— Dyspnoea 
— [Dyspnoea  of  pregnancy] — Palpitation — Syncope — Anseraia  and  Chlorosis — 
[Pernicious  anaemia  in  parturient  women] — Albuminuria 199 


CHAPTER    VIIL 

DISEASES    OF   PREGNANCY    {continued). 

Disorders  of  the  Nervous  System  ;  Insomnia,  Headaches  and  Neuralgia,  Paraly- 
sis— Chorea;  Disorders  of  the  Urinary  Organs ;  Retention  of  Urine,  Irrita- 
bility of  the  Bladder — [Eneuresis  of  pregnancy] — Incontinence  of  LTrine, 
Phosphatic  Deposits — Leucorrhcea — Effects  of  Pressure — Laceration  of  Veins 
—Displacements  of  the  Gravid  Uterus;  Prolapse,  Anteversion,  Retroversion 
— Diseases  co-existing  with  Pregnancy  :  Eruptive  Fevers,  Smallpox,  Measles, 
Scarlet  Fever,  Continued  Fever,  Phthisis,  Cardiac  Disease,  Syphilis,  Icterus, 
Carcinoma — Pregnancy  complicated  with  Ovarian  and  Fibroid  Tumors  .    .    •    212 


CHAPTER    IX. 

PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 

Pathology  of  the  Decidua — Hydrorrhcea  Gravidarum — Pathology  of  the  Chorion  ; 
Vesicular  Degeneration,  Myxoma  Fibrosum — Pathology  of  the  Placenta  ; 
Blood-Extravasations,  Fatty  Degeneration,  etc.- — Pathology  of  the  Umbilical 
Cord — [Corkscrew  funis] — Pathology  of  the  Amnion — [Hydramnios] — De- 
ficiency of  Liquor  Amnii,  etc. — Pathology  of  the  Foetus ;  Blood  Diseases 
througli  the  Mother,  Smallpox,  Measles,  and  Scarlet  Fever,  Intermittent 
Fevers,  Lead- Poisoning,  Syphilis — Inflammatory  Diseases — Dropsies — Tumors 
— Wounds  and  Injuries  of  the  Foetus — Intra-uterine  Amputations — [Arrested 

pullulation] — Death  of  the  Foetus 2i 

2 


Xll  COyTESTS. 

CHAPTER    X. 
ABORTION    AND    I'REMATL'RE    LABOR. 

PAGE 

Importance  and  Frequency — Definition  and  Classification — Frequency — Recur- 
rence— Causes — Causes  referable  to  Fa?tus — Changes  in  a  Dead  Ovum  retained 
in  Utero — Extravasations  of  Blood — Moles,  etc. — Causes  depending  on  Mater- 
nal State,  Syphilis— Causes  acting  tlirough  Nervous  System,  Physical  Causes, 
etc.— Causes  depending  on  Morbid  States  of  Uterus — Symptoms— Preventive 
Treatment— [Opiate  treatment  in  threatened  abortion] — Prophylactic  Treat- 
ment—  [Viburnum  prunifolium  in  threatened  abortion] — Treatment  when 
Abortion  is  inevitable — After-treatment 247 


PART   IIT. 

LABOR. 


CHAPTER    I. 

THE    PHENOMENA    OE    LABOR. 

Causes  of  Labor — Mode  in  which  the  Expulsion  of  the  Child  is  effected — The 
Uterine  contraction — Mode  in  which  the  Dilatation  of  the  Cervix  is  effected 
—Rupture  of  the  Membranes — Character  and  source  of  Pains  during  Labor 
— Effect  of  Pains  on  Mother  and  Foetus — Division  of  Labor  into  Stages — 
Preparatory  Stage — False  Pains — First  Stage — Second  Stage — Third  Stage — 
Mode  in  which  the  Placenta  is  expelled — Duration  of  Labor 259 

CHAPTER    IL 

MECHANISM    OF   DELIVERY    IN    HEAD    PRESENTATIONS. 

Importance  of  Subject — Frequency  of  Head  Presentation — The  different  jio-sitions 
of  the  Head — F^irst  Position — Division  of  Mechanical  movements  into  Stages 
— Flexion — Descent  and  Levelling  Movement — Rotation — Extension — Exter- 
nal Rotation — Second  Position — Third  Position — Fourth  Position — Caput 
Succedaneum — Alteration  in  Shape  of  Head  from  Moulding 272 

CHAPTER    TIL 

MAN.\GEMENT  OF  NATFRAI,  LABOR. 

Preparatory  Treatment — Dress  of  Patient  during  Pregnancy — The  Obstetric  Bag 
— Duties  on  first  visiting  Patient — False  Pains — Their  Character  and  Treat- 
ment—  [Kelly's  rubber  protector  in  parturient  cases] — Vaginal  F^xamination 
— ^The  Position  of  Patient — Artificial  Rupture  of  Membranes — Treatment  of 
Propulsive  Stage — Relaxation  of  the  Perineum — Treatment  of  Lacerations — 
Expulsion  of  Child— Promotion  of  Uterine  Contraction — Ligature  of  the  Cord 
— Management  of  the  Third  Stage  of  Labor — [Expidsion  of  Placenta] — Ap- 
Jjlicatioa  of  the  Binder — After-treatment        284 


CONTENTS.  xiii 

CHAPTER    IV. 

ANESTHESIA    IN    LABOR. 

PAGE 

Agents  employed — Chloral ;  its  Object  and  Mode  of  Administration — Ether — 
Chloroform  ;  its  Use,  Objections  to,  and  Mode  of  Administration — [Ether  safer 
than  Chloroform] 299 

CHAPTER    V. 

PELVIC    PRESENTATIONS. 

Frequency — Causes — Prognosis  to  Mother  and  Child — Diagnosis  by  Abdominal 
Palpation  and  by  Vaginal  Examination — [Bimanual  Version  in  breech  cases] 
— Differential  Diagnosis  of  Breech,  Knee,  and  Feet — Mechanism — Treatment 
— Management  of  Impacted  Breech  Presentations— [Breech  forceps]  ....    303 

CHAPTER    VI. 

PRESENTATIONS    OF    THE    FACE. 

Erroneous  Views  formerly  held  on  the  Subject — Frequency — Mode  of  Production 
— Diagnosis — Mechanism — Four  Positions  of  the  Face — Description  of  De- 
livery in  First  Face  Position — Mento-posterior  Position  in  which  Rotation 
does  not  take  place — Prognosis — Treatment — Bi'ow  Presentation — [Version 
by  the  Vertex]      315 

CHAPTER    VII. 

DIFFICULT    OCCIPITO-POSTERIOR    POSITIONS. 

Causes  of  Face-to-Pubes  Delivery — Mode  of  Treatment — Upward  Pressure  on 
Forehead — Downward  Traction  on  Occiput — Use  of  Forceps — Peculiarities 
of  Forceps  Delivery 324 

CHAPTER    VIII. 

PRESENTATIONS    OF    SHOULDER,    ARM,    OR    TRUNK— COMPLEX    PRESENTATIONS- 
PROLAPSE    OF    THE    FUNIS. 

Position  of  the  Foetus — Division  into  Dorso-anterior  and  Dorso-posterior  Posi- 
tions—  Causes — Prognosis  and  Frequenc)' — Diagnosis — Mode  of  distinguishing 
Position  of  Child — Differential  Diagnosis  of  Shoulder,  Elbow,  and  Hand — 
Mechanism — The  two  possible  Modes  of  Delivery  by  the  Natural  Powers — 
Spontaneous  Version — Spontaneous  Evolution — Treatment — [Cesarean  Opera- 
tion for  foetal  impaction] — Complex  Presentation;  Foot  or  Hand  with  Head; 
Hand  and  Feet  together — Dorsal  Displacement  of  the  Arm — Prolaj^se  of  the 
Umbilical  Cord — Frequency — Prognosis — Canses — Diagnosis — Postural  Treat- 
ment— Artificial  Reposition — Treatment  when  Reposition  fails 328 


PAGE 


xiv  CONTENTS. 

CHAPTER    IX. 

PROLONGED    AND    I'KECMMTATK    LABORS. 

Evil  Effects  of  Prolonged  Labor — InllueiK-e  of  the  Stage  of  Labor  in  Protraction 
— Delay  in  the  Fii"st  Stage  rarely  serious — Tennmrary  Cessation  of  Pains — 
Symptoms  of  Protraction  in  the  Second  Stage  — State  of  the  L" terns  in  Pro- 
tracted Labor — Causes  of  Protraction  due  to  morltid  condition  of  tiie  expul- 
sive powers — [Recurrent  Uterine  Fatigue] — Causes  of  Protraction — Treatment 
— Oxytocic  Remedies — Ergot  of  Rye,  etc. — Manual  Pressure — In.strumental 
Delivery  (case of  Princess  Charlotte  of  Wales) — [Kre(iuent  use  of  Forceps] — 
Precipitate  Labor — Its  Causes  and  Treatment — [Rapid  Delivery] 342 

CHAPTER    X. 

LABOR    OBSTRUCTED    BY    FAULTY    CONDITION    OF    THE  SOFT    PARTS. 

Rigidity  of  the  Cervix  ;  its  Causes,  Effects,  and  Treatment — [Csesarean  Section  in 
Cancer  of  Cervix] — Ante-partum  Hour-glass  Contraction — ["  Circular  Contrac- 
tion of  the  middle  of  the  Womb"  (Blundellj] — Bands  and  Cicatrices  in  the 
Vagina — Extreme  Rigidity  of  the  Perineum — Labor  complicated  with  Tumor 
— [Cesarean  Results  in  Tumor  Cases] — [Prolapsed  Dermoid  Cyst  obstructing 
Delivery] — Vaginal  Cystocele — Calculus — Hernial  Protrusions — [Impaction 
of  Bowels  from  eating  Clay] — (Edema  of  Vulva — Haematic  Effusions,  etc. — 
[Polypus  obstructing  Delivery] 358 

CHAPTER    XI. 

DIFFICULT    LABOR   DEPENDING  ON  SOME    UNUSUAL    CONDITION   OF    THE    FCETUS. 

Plural  Births,  Treatment  of — Locked  Twins — Conjoined  Twins — Intra-uterine 
Hydrocephalus:  Its  Dangers,  Diagnosis,  and  Treatment — Other  Dropsical 
Effusions — Foetal  Tumor; — Excessive  Development  of  Foetus 370 

CHAPTER    XII. 

DEFORMITIES    OF    THE    PELVIS. 

Classification — Causes  of  Pelvic  Deformity — Rickets  and  Osteomalacia — The 
Equally-Enlarged  Pelvis  — The  Equally-Contracted  Pelvis  — The  Unde- 
veloped Pelvis — [Small  Pelvis,  marked  by  External  Development  of  Adi- 
pose Tis.sue] — Miusculine  or  Funnel-shaped  Pelvis— Contraction  of  Conjugate 
Diameter  of  the  Brim — [Spinal  :ind  Pelvic  Deformity  associated] — Figure- 
of-eight  Deformity — [Spondyl-olisthesis] — Spondylolizema — Narrowing  of  the 
OVjli(|ue  Diameters — [Osteomalacia  not  an  American  Disease]  — Obliquely-C(tn- 
tracted  Pelvis — [Coxalgic  Deformity  of  Pelvis] — Kyphotic  Pelvis — Robert's 
Pelvis — Deformity  from  old-standing  Hip-joint  Disea.se — Deformity  from 
Tumors,  Fractures,  etc. — Effects  of  Contracted  Pelvis  f>n  Lalior — Risks  to 
the  Mother  and  ('hild — [Pelvic  Exostosis  obstructing  Delivery] —Mechan- 
ism of  Delivery  in  Head  Presentation  :  «,  in  Contracted  Brim  ,  /»,  in  Generally- 
Contracted  Pelvis — Diagnosis — External  Measurements — Internal  Measure- 
ments-Mode of  Estimating  the  Conjugate  Diameter  of  the  Brim — Mode  of 
Diagnosing  the  Oblique  Pelvis — Treatment — The  Forceps — Turning — Crani- 
otomy— The  Induction  of  Premature  Labor — Induction  of  Abortion — [Dan- 
gers of  Casarean  Section  Overestimated] 382 


CONTENTS.  XV 

CHAPTER    XIII. 

HEMORRHAGE    BEFORE    DELIVERY:    PLACENTA    PREVIA. 

PAGE 

Definition — Causes — Symptoms — Sources  and  Causes  of  Ilemorrliage — Prognosis 
— Treatment-  [Braxton  Hicks'  Bimanual  Method  of  Turning  in  Placenta 
Previa] 407 

CHAPTER    XIV. 

HEMORRHAGE    FROM    SEPARATION    OF    A    NORMALLY    SITUATED    PLACENTA. 
Causes  and  Pathology — Symptoms  and  Diagnosis — Prognosis — Treatment    .    .    .    418 

CHAPTER    XV. 

HEMORRHAGE    AFTER    DELIVERY'. 

Its  Frequency — Generally  a  Preventable  Accident — Causes — Nature's  Method  6t 
Controlling  Hemorrhage  —  Uterine  Contraction  —  Thrombosis  —  Secondary 
Causes  of  Hemorrhage — Irregular  Uterine  Contraction — Placental  Adhesions 
— Constitutional,  Predisposition  to  Flooding — Symptoms — Preventive  Treat- 
ment— Curative  Treatment — Secondary  Treatment — [Hot-water  Injections  of 
Uterus] — [Head  Lowered  and  Body  Elevated  in  Fainting  from  Hemorrhage] 
— Secondary  Post-partum  Hemorrhage — Its  Causes  and  Treatment 421 

CHAPTER    XVI. 

RUPTURE    OF  THE    UTERUS,    ETC. 

Its  Fatality— Seat  of  Rupture— Causes,  Predisposing  and  Exciting — Symptoms 
— Prognosis— Treatment;  when  the  Foetus  Remains  in  ittero,  when  the  Fo?tus 
has  Escaped  from  the  Uterus— [Prevot's  Supravaginal  Amputation  of  Uterus] 
— Lacerations  of  the  Cervix — Recapitulation — Lacerations  of  the  Vagina — 
Vesico-  and  Recto-vaginal  Fistul?e — Their  Mode  of  Formation — Treatment— 
[Rational  Treatment  of  Rupture  of  the  Uterus] 438 

CHAPTER    XVII. 

INVERSION    OF    THE    UTERUS. 

Division  into  Acute  and  Chronic  Forms— Description— Symptoms— Diagnosis- 
Mode  of  Production — Treatment— [Spontaneous  Reposition  of  the  Inverted 
Uterus] 449 


xvi  coyrEyrs. 


PART  IV. 

OBSTETRIC    OPERATIONS. 


CHAPTER    I. 

INDUCTIOX   OF    PREMATURE    LABOR. 

PAGE 

History — Objects — May  be  Performed  on  account  eillier  of  tlie  Mother  or  Child 
— Modes  of  Inducing  Labor — Puncture  of  Meni})ranes — Administration  of 
Oxytocics — Means  acting  Indirectly  on  the  Uterus — Dilatation  of  Cervix — 
Separation  of  Membranes — Vaginal  and  Uterine  Douches — Introduction  of 
Flexible  Cathetei- — [Infantile  Mortality  after  Induction  of  Premature  Labor]  456 


CHAPTER    IL 

TURNING. 

History — Turning  by  External  Manipulation — Object  and  Nature  of  the  Opera- 
tion— Cases  Suitable  for  the  Operation — Statistics  and  Dangers — Method  of 
Performance — Cephalic  Version — Method  of  Performance — Podalic  Version 
— Position  of  Patient — Administration  of  Antesthetics — Period  when  the 
Operation  should  be  Undertaken — Choice  of  Hand  to  be  Used — Turning  l)y 
Bipolar  Method — Turning  when  the  Hand  is  Introduced  into  the  Uterus — 
Turning  in  Abdomino-anterior  Positions — Difficult  Cases  of  Arm  Presentation 
— [The  Forceps  in  America] 464 


CHAPTER    in. 

THE    FORCEPS. 

Frequent  Use  of  the  Forceps  in  Modern  Practice — Description  of  the  Instrument 
— Tiie  Short  Forceps — Its  Varieties— The  Long  Forceps — Suitable  to  all  Cases 
alike — Action  of  the  Instrument— Its  Power  as  a  Tractor,  Lever,  and  Com- 
pressor— Preliminary  Consideratif)ns  before  Operation — U.se  of  Anaesthetics — 
Description  of  the  Operation— Low  Forceps  Operation  — High  Forceps  ( )pera- 
tion — Possible  Dangers  of  Forceps  Delivery — Possible  Risks  to  the  Child  .    .    478 


CHAPTER    IV. 

THE    VKCTIS— THE    FILLET. 

Nature  of  the  Vectis — Its  Use  as  a  Lever  or  Tractor — Ca.'^es  in  which  it  is  .Appli- 
cable— Its  Use  as  a  Rectifier  of  Malpositions— The  Fillet — Nature  of  the 
Instrument — Objections  to  its  Use 502 


CONTENTS.  XVll 

CHAPTER    V. 

OPERATIONS    INVOLVING    DESTRUCTION    OF    THE    FfETUS. 

PAGE 

Their  Antiquity  and  History— Division  of  Subject — Nature  of  Instruments  Em- 
ployed—Perforator— Crotchet — Craniotomy  Forceps— Cephalotribe — Forceps- 
saw — Ecraseur — Basilyst — Cases  requiring  Craniotomy — Metliod  of  Perfora- 
tion— Extraction  of  the  Head— Comparative  Merits  of  Cephalotri{)sy  and 
Craniotomy — Extraction  by  the  Craniotomy  Forceps — Extraction  of  the  Body 
— [Meigs'  Craniotomy  Forceps]— Embryotomy — Decapitation  and  Eviscera- 
tion       504 


CHAPTER    VI. 

THE    C^.SAREAN    SECTION-PORRO'S    OPERATION-SYMPHYSIOTOMY. 

History  of  tlie  Operation— [Macduff's  Delivery]— Statistics— [Old  Caesarean  Rec- 
ords of  little  Practical  Value  now]— [Csesarean  Section  in  America] — Re- 
sults to  Mother  and  Child — Causes  Requiring  the  Operation — [Csesarean  Sec- 
tion under  Relative  Indications] — Post-mortem  Csesarean  Section — Causes  of 
Death  after  the  Csesarean  Section — [Csesarean  Section,  causes  of  Death  fol- 
lowing]—[Csesarean  Section  performed  Prior  to  Labor] — Preliminary  Prepa- 
rations— [Color-line  of  Abdomen  in  Pregnant  Women] — Description  of  the 
Operation — [Sutures  in  Csesarean  Operations] — Subsequent  Management — 
Porro's  Operation— [Porro  Operation  in  Great  Britain] — [Porro  Statistics] — 
Substitutes  for  the  Csesarean  Section— Symphysiotomy — [Symphysiotomy  in 
Naples] 518 


CHAPTER    VII. 

LAPARO-ELYTROTOMY. 

History — [Statistics  of  Laparo-elytrotomy] — Nature  of  the  Operation — Advan- 
tages over  the  Csesarean  Section— Cases  Suitable  for  the  Operation — [Laparo- 
elytrotomy  Inadmissible  in  many  Cases  of  Labor] — Anatomy  of  the  Parts 
concerned  in  the  Operation — Method  of  Performance — Subsequent  Treatment 
— [Laparo-elytrotomy  performed  on  Either  Side] 534 


CHAPTER    VIII. 

THE    TRANSFUSION    OF    BLOOD. 

History — Nature  and  Object  of  the  Operation — Use  of  Blood  taken  from  the 
Lower  Animals — Difficulties  from  Coagulation  of  Fibrin — Modes  of  Obviat- 
ing them — Immediate  Transfusion — Addition  of  Chemical  Agents  to  prevent 
Coagulation — Defibrination  of  the  Blood — Statistical  Results — Possible  Dan- 
gers of  the  Operation — Cases  suitable  for  Transfusion — Description  of  the 
Operation — Schilfer's  Directions  for  Immediate  Transfusion — Effects  of  Suc- 
cessful Transfusion — Secondary  Effects  of  Transfusion— [Transfusion  with 
Defibrinated  Blood] 539 


A  VIII  COSTEMS. 

PART  V. 

THE   PUE  It  r  E  R  A  L    STATE. 


CHAPTER    I. 

THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT, 

PAGE 

Importance  of  Studying  llie  Puerperal  State— Tlie  Mortality  of  Childbirih — 
Alterations  in  the  Blood  after  Delivery — Condition  after  Delivery — Nervous 
Shock — Fall  of  tlie  Pulse— The  Secretions  and  Excretions — Secretion  of  Milk 
— Changes  in  the  Uterus  after  Delivery — The  Lochia— The  Afler-pains — 
Management  of  Women  after  Delivery — Treatment  of  Severe  After-pains — 
Diet  and  Kegimen 551 

CHAPTER    II. 

MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC. 

Commencement  of  Respiration  after  tlie  Birth  of  the  Child — Apparent  Death  of 
the  Newborn  Child — Its  Treatment — "Washing  and  Dressing  the  Child — Ap- 
])lication  of  the  Child  to  the  Breast — Tiie  Colostrum  and  its  Properties — Secre- 
tion of  Milk — Importance  of  Nursing — Selection  of  a  Wet-nurse — [Diet  proper 
for  Wet-nurses] — Management  of  Lactation — Diet  and  Regimen  of  Nursing 
Women — Period  of  ^Veaning — Disorders  of  Lactation — Means  of  Arresting 
the  Secretion  of  Milk — Defective  Secretion  of  Milk — [Milk-diet  for  Nursing 
Mothers] — Depressed  Nipples— Fissures  and  Excoriations  of  the  Nipples — 
Excessive  Flow  of  Milk — Mammary  Abscess— Hand-feeding — Causes  of  Mor- 
tality in  Hand-feeding — Various  Kinds  of  Milk — Method  of  Hand-feeding  .    562 

CHAPTER    III. 
PUERPERAL    ECLAMPSIA. 

Its  Doubtful  Etiology — Premonitory  Symptoms — Symptoms  of  the  Attack — Con- 
dition between  the  Attacks — Relation  of  the  Attacks  to  Labor — Results  to 
Mother  and  Child — Pathology — Treatment — Obstetric  Management — [Urine 
to  be  Examined  in  Eclamptic  Cases] 578 

CHAPTER    IV. 
PUERPERAL    INSANITY. 

Classification — Proportion  of  Various  Ff)rms — Insanity  of  Pregnancy — Predis- 
posing Causes — Period  of  Pregnancy  at  whicli  it  Occurs — Type  of  Insanity — 
Prognosis  Transient  Mania  during  Delivery — Puerj)eral  Insanity  (pro|)er) 
— Type  of  Insanity — Causes — Theory  of  its  De])endence  on  a  Morbid  State  of 
the  Blood — Objections  to  the  Theory — Prognosis — Post-n)ortem  Signs — Dura- 
tion— Insanity  of  Lactation — Type— Symptoms — Of  Mania — Of  Melancholia 
— Treatment — (Question  of  Removal  to  Asyliun — Treatment  during  Conva- 
lescence   587 


CONTENTS.  XIX 

CHAPTER    V. 
PUERPERAL   SEPTICAEMIA. 

PAGE 

Differences  of  Opinion— Confusion  from  this  Cause — Modern  View  of  tliis  Dis- 
ease— History — Its  Mortality  in  Lying-in  Hospitals— Numerous  Theories  as 
to  its  Nature — Theory  of  Local  Origin— Theory  of  an  I']ssential  Zymotic 
Fever — Theory  of  its  Identity  with  Surgical  vSeptiat'inia — Nature  of  this 
^'iew — Channels  through  whicli  Septic  Matter  may  be  Absorbed— Character 
and  Origin  of  Septic  Matter  often  Obscure — Division  into  Autogenetic  and 
Heterogenetic  Cases— Sources  of  Self-infection — Sources  of  llelerogenetic 
Infection— Influence  of  Cadaveric  Poison— Infection  from  Erysipelas— Infec- 
tion from  other  Zymotic  Diseases— Infection  from  Sewer  Gas— Ceases  illustrat- 
ing this  Mode  of  Infection— Contagion  from  other  Puerperal  Patients— Mode 
in  which  the  Poison  may  be  Conveyed  to  the  Patient — Conduct  of  the  Prac- 
titioner in  Relation  to  the  Disease— Nature  of  the  Septic  Poison— Local  Changes 
resul.ting  from  the  Absorption  of  Septic  Material  —  Channels  through 
which  Systemic  Infection  is  Produced — Pathological  Phenomena  observed 
after  general  Blood  Infection — Four  Principal  Types  of  Pathological  Change 
— Intense  Cases  without  marked  Post-mortem  Signs— Cases  Characterized  by 
Inflammation  of  the  Serous  Membranes— Cases  Characterized  by  the  Impac- 
tion of  Infected  Emboli  and  Secondary  Inflammation  and  Abscess — Descrip- 
tion of  the  Disease — Duration— Varieties  of  Symptoms  in  Different  Cases- 
Symptoms  of  Local  Complications — Treatment 598 


CHAPTER    VI. 

PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM. 

Puerperal  Thrombosis  and  its  Results — Conditions  which  favor  Thrombosis — Con- 
ditions which  favor  Coagulation  in  the  Puerperal  State — Distinction  between 
Thrombosis  and  Embolism — Is  Primary  Thrombosis  of  the  Pulmonary  Arteries 
possible  ? — History — Symptoms  of  Pulmonary  Obstruction — Is  Recovery  pos- 
sible ? — Causes  of  Death — Post-mortem  Appearances — Treatment — Puerperal 
Pleuro-pneumonia ;  its  Causes  and  Treatment 629 


CHAPTER    VII. 

PUERPERAL    ARTERIAL    THROMBOSIS    AND    EMBOLISM. 
Causes — Symptoms — Treatment 6-11 

CHAPTER    VIII. 

OTHER  CAUSES  OF  SUDDEN  DEATH  DURING  LABOR  AND  THE  PUERPERAL  STATE. 

Organic  and  Functional  Causes — Idiopathic  Asphyxia — Pulmonary  Apoplexy — 
Cerebral  Apoplexy — Syncope — Shock  and  Exhaustion — Entrance  of  Air  into 
the  Veins G43 


XX  COyTEXTS. 

(  HAPTKR    L\. 

PERiniERAL  VENOUS  THROMBOSIS   (SYN.:   CKrUAL    rHI.ERITIR-PnLEr.MASIA 
DOI.KNS-ANASARCA    SEKOSA-0:DEMA    LACTErM-WllITE    I,E<i,    ETC.) 

I-ACiE 

Nature — Svniptoms — History  and  I'atliology — Aiiatoinical  Form  of  the  Tlironilii 
in  tlie  Veins — Detarlunent  of  Eniljoli — [Crural  Phlebitis  after  Cesarean  and 
I'orro  Operations] — Treatment G45 


CHAPTER    X. 

PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS. 

Two  Forms  of  Disease — Variety  of  Nomenclature — Importance  of  Differential 
Diagnosis — Etiology — Connection  with  Septica?mia — Seat  of  Inflammation — 
Relative  Frequency  of  the  Two  Forms  of  Disease — Symptomatology— Results 
of  Physical  Examination— Terminations — Prognosis— Treatment (352 


INDEX •    •    ■ *36l 


ILLUSTRATIONS. 


Plate  I. — Section  of  a  Frozen  Body  in  the  last  months  of  Pregnancy  (after 
Braune).  Ilhistrating  the  Relations  of  the  Uterus  to  the  surrounding  Parts, 
and  the  attitude  of  the  P^oetus,  which  is  lying  in  the  second  Cranial  Posi- 
tion      Frontupiece 

Plate  II. — Section  of  a  Frozen  Body  at  the  termination  of  the  First  Stage  of 
Labor  (after  Braune).  Membranes  unbroken  ;  Cervix  fully  dilated;  and  the 
Head  (in  the  Second  Position)  in  the  Pelvic  Cavity Front inpiece 

Plate  III. — Illustrations  of  the  Corpora  Lutea  of  Menstruation  and  Pregnancy. 

(After  Dalton.) To  face  page  62 

Plate  IV. — Vertical  Mesial  Section  of  Uterus  with  Placenta  partially  attached. 

(After  Barbour.) To  face  page  110 

Plate  V. — Vertical  Mesial  Section  (frozen)  of  Pelvis  with  Post-partum  Uterus. 

To  face  page  234 

FIG.  PAGE 

1.  Os  innominatum 34 

2.  Sacrum  and  Coccyx 35 

3.  Section  of  Pelvis  and  heads  of  Thigh-bones,  showing  the  Suspensory  Action 

■  of  the  Sacro-iliac  Ligaments.     (After  Wood.) 36 

4.  Outlet  of  Pelvis 40 

5.  The  Female  Pelvis 40 

6.  The  Male  Pelvis 41 

7.  Brim  of  Pelvis,  showing  Antero-posterior,  Oblique,  and  Transverse  Diameters  41 

8.  Section  of  Pelvis,  showing  the  Diameters 42 

9.  Planes  of  the  Pelvis,  with  Horizon 44 

10.  Axes  of  the  Pelvis 45 

11.  Representing  General  Axis  of  the  Parturient  Canal,  including  the  Uterine 

Cavity  and  Soft  Parts 45 

12.  Side  view  of  Pelvis 46 

13.  Pelvis  of  a  Child 47 

14.  External  Genitals  of  Virgin  with  Diaphragmatic  Hymen.     (After  Sappey.)  50 

15.  Vascular  Supply  of  Vulva.     (After  Kobelt.)         54 

16.  Right  Half  of  Virgin  Vagina  with  Walls  held  apart,  showing  the  abundant 

transverse  Rugre,  the  greater  depth  of  the  Vagina  above  than  below,  and 

the  Hymeneal  Segment.     (After  Hart) 55 

17.  Longitudinal  Section  of  Body,  showing  Relations  of  the  Generative  Organs  .  55 

18.  Transverse  Section  of  Body,  showing  Relations  of  the  Fundus  Uteri  ....  57 

19.  Transverse  Section  of  Uterus 57 

20.  Uterus  and  Appendages  in  an  Infant.    (After  Farre.) 58 

21.  Portion  of  Interior  of  Cervix.     (Enlarged  nine  times. ) 60 

22.  Muscular  Fibres  of  Unimpregnated  Uterus.     (After  Farre.) 60 

23.  Developed  Muscular  Fibres  from  the  Gravid  Uterus.    (After  Wagner.)  .    .    .  60 

24.  Lining  Membrane  of  Uterus,  showing  Network  of  Capillaries  and  Orifices  of 

Uterine  Glands.     (After  Farre.j 62 

xxi 


xxii  ILL  USTRA  TTOXS. 

fIG.  PAOK 

25.  The  Course  of  tlie  Glands  in  tlie  fully-developed  Mucous  Membrane  of  the 

Uterus.     (After  Williams.) 03 

26.  Vertical   Section    through  the   Mucous   Membrane   of  the  Human  Uterus. 

(After  Turner.) 64 

27.  Villi  of  Os  Uteri  stripped  of  Epithelium.    (.After  Tyler  Smith  and  Hassall.j  05 

28.  Villi  of  Uterus,  covered  with  Pavement  Epithelium,  and  containing  Looped 

Vessels.     (After  Tyler  Smith  and  Hassall.) 65 

29.  Bifid  Uterus.     (After  Farre.) 67 

30.  [Uterus  Septus  Uniforis.     (From  Kussmaul,  after  Gravel.)] 68 

31.  Adult  Parovarium,  Ovary,  and  Fallopian  Tube.     (After  Kobelt.) 69 

32.  Posterior  View  of  Muscular  and  Vascular  Arrangements.     (After  Rouget.)  .  7U 

33.  Fallopian  Tube  laid  open.     (After  Richard.) 72 

34.  Ovary  enlarged  under  Menstrual  Nisus 74 

35.  Longitudinal  Section  of  Adult  Ovary.     (After  Farre.) 75 

36.  Section  through  the  Cortical  Part  of  the  Ovary.     (After  Turner.) 76 

37.  Vertical  Section  through  the  Ovary  of  the  Human  Foetus.     (After  Foulis.)  .  76 

38.  Diagrammatic  Section  of  Graafian  Follicle 77 

39.  Bulb  of  Ovary 79 

40.  Mammary  Gland 80 

4L  Section  of  Ovary,  showing  Corpus  Luteum  three  weeks  after  Menstruation. 

(After  Dalton.) 83 

42.  Corpus  Luteum  at  the  fourth  month  of  Pregnancy.     (After  Dalton.)  ....  85 

43.  Corpus  Luteum  of  Pregnancy  at  Term.     (After  Dalton.) 85 

44.  Section  of  Parts  of  three  Seminiferous  Tubules  of  the  Rat.   (From  a  prepara- 

'  tion  by  Mr.  A.  Eraser.) 90 

45.  Ovum  of  a  Rabbit  containing  Spermatozoa 98 

46.  Formation  of  the  "  Polar  Globule  " 99 

47.  Sections  of  the  Ovum  of  the  Rabbit  during  the  last  Stages  of  Segmenta- 

tion, showing  the  Formation  of  the  Blastodermic  Vesicle.     (After  E.  v.. 

Beneden.) 100 

48.  Formation  of  the  Blastodermic  Membrane.     (After  .Joulin.) 101 

49.  Aborted  Ovum  (of  about  forty  days),  showing  the  Triangular  Shape  of  the 

Decidua  (which  is  laid  open),  and  the  Aperture  of  the  Fallopian  Tube. 

(After  Coste.) 102 

50.) 

51.  r    Formation  of  the  Decidua.     (After  Dalton.) 103 

52.  J 

53.  An  Ovum  removed  from  the  Uterus,  and  part  of  the  Decidua  Vera  cut  away. 

(After  Coste.) 104 

54.  Diagram  of  Area  Germinativa,  showing  the  Primitive  Trace  and  Area  Pel- 

lucida 106 

55.  Development  of  the  Amnion 107 

56.  Development  of  the  Umbilical  Vesicle  and  Amnion 108 

57.  An  Embryo  of  about  twenty-five  days  laid  open.     (After  Coste.) 108 

58.  Development  of  the  Chorion 109 

59.  Five  diagrammatic  Figures  illustrating  the  Formation  of  the  Foetal  Mem- 

branes of  a  Mammal.     (After  Kolliker.) Ill 

60.  Placental  Villus,  greatly  magnified.     (After  Joulin.) 115 

61.  Terminal  Villus  of  Foetal  Tuft,  minutely  ejected.     (After  Farre.) 116 

62.  Diagram  reiiresenting  a  Vertical  Section  of  the  Placenta.     (After  Dalton.)  .  117 

63.  Diagram  illustrating  the  Mode  in  which  a  Placental  Villus  derives  a  Cover- 

ing from  the  Vascular  System  of  the  Mother.     (After  Priestley.)   .    .    ;    .  117 

64.  The  Extremity  of  a  Placental  Villus.     (After  Goodsir.) 117 

65.  Anterior  and  Posterior  Fontanelles 124 


ILL  USTRA  TIONS.  x  xiii 

PIG.  PAGE 

QQ.  Bi-parietal  diameter,  Sagittal  and  Lambdoidal  Sutures,  with  Posterior  Fon- 

tanelle 124 

67.  Diameters  of  the  Foetal  Skull 125 

68.  Mode  of  Ascertaining  the  Position  of  the  Foetus  by  Palpation 127 

69.  Diagram  illustrating  the  Effect  of  Gravity  on  the  Foetus.     (After  Duncan.)  129 

70.  Illustrating  tlie  greater  Mobility  of  the  Foetus  and  the  larger  relative  amount 

of  Liquor  Amnii  in  Early  Pregnancy.     (After  Duncan.) 129 

71.  Diagram  of  Foetal  Heart.     (After  Dalton.) 133 

72.  Diagram  of  Heart  of  Infant.     (After  Dalton.) 134 

73.  'Relations  of  Pregnant  Uterus  at  six  months.     (After  Martin.) 1.37 

74.  Size  of  Uterus  at  Various  Periods  of  Pregnancy 138 

76.  j     Supposed  Shortening  of  the  Cervix  at  the  third,  sixth,  eighth,  and  ninth 

77-  I        months  of  Pregnancy,  as  figured  in  Obstetric  Works 140 

78.  J 

79.  Cervix  of  a  Woman  Dying  in  the  Eighth  Month  of  Pregnancy.     (After 

Duncan.) 140 

80.  Appearance  of  the  Areola  in  Pregnancy 151 

81.  Illustrating  the  Cavity  between  the  Decidua  Vera  and  the  Decidua  Reflexa 

during  the  early  Months  of  Pregnancy.     (After  Coste.) 175 

82.  Tubal  Pregnancy,  with  the  Corpus  Luteum  in  the  Ovary  of  the  opposite  side  179 

83.  Tubal  Pregnancy.     (From  a  specimen  in  the  Museum  of  King's  College.)  .  180 

84.  Extra-uterine  Pregnancy  at  term  of  the  Tubo-ovarian  Variety.     (After  a 

case  of  Dr.  A.  Sidney  Campbell's.) 182 

85.  Uterus  and  Foetus  in  a  case  of  Abdominal  Pregnancy 187 

86.  Lithopsedion.     (From  a  preparation  in  the  Museum  of  the  Royal  College 

of  Surgeons.) 188 

87.  Contents  of  the  Cyst  in  Dr.  Oldham's  case  of  Missed  Labor ,  194 

88.  Hypertrophied  Decidua  laid  open,  with  the  Ovum  attached  to  its  Fundal 

Portion.     (After  Duncan.) 229 

89.  Imperfectly  developed  Decidua  Vera,  with  the  Ovum.     (After  Duncan.)  .    .  230 

90.  Hydatidiform  Degeneration  of  the  Chorion 232 

91.  Myxoma  Fibrosum  of  the  Placenta.     (After  Storch.) 235 

92.  Double  Placenta,  with  Single  Cord 236 

93.  Fatty  Degeneration  of  the  Placenta 237 

94.  Knots  in  the  Umbilical  Cord 238 

95.  Intra-uterine  Amputation  of  both  Arms  and  Legs 244 

96.  An  Apoplectic  Ovum,  with  Blood  efTused  in  masses  under  the  Foetal  Surface 

of  the  Membranes 249 

97.  Blighted  Ovum,  with  Fleshy  Degeneration  of  the  Membranes 250 

98.  Mode  in  which  the  Placenta  is  Naturally  Expelled.     (After  Duncan.)     .    .  270 

99.  Attitude  of  Child  in  First  Position.     (After  Hodge.) •   .  275 

100.  First  Position  :  Movement  of  Flexion 275 

101.  First  Position :  Occiput  in  Cavity  of  Pelvis.     (After  Hodge.) 277 

102.  First  Position  :  Occiput  at  Outlet  of  Pelvis.     (After  Hodge.) 278 

103.  First  Position :  Head  Delivered.    (After  Hodge.) 279 

104.  External  Rotation  of  Head  in  First  Position.     (After  Hodge.) 280 

105.  Third  Position  of  Occiput  at  Brim  of  Pelvis 281 

106.  Fourth  Position  of  Occiput  at  Pelvic  Brim 283 

107.  Examination  during  the  First  Stage  of  Labor 288 

108.  Mode  of  EflTecting  Relaxation  of  the  Perineum      292 

109.  Usual  Method  of  Removing  the  Placenta  by  Traction  on  the  Cord    ....  296 

110.  Illustrating  Expression  of  the  Placenta 297 

111.  First,  or  left  Sacro-anterior  Position  of  the  Breech 308 


X  X i  V  ILL  VST II .  1  Tinys. 

FIG.  PACK 

112.  Piissage  of  the  Slioulilers  and  Partial  liotiuion  of  the  Tliorax 808 

113.  Descent  of  t lie  Head 809 

114.  Third  Position  in  Face  Presentation 818 

115.  Kotation  forward  of  Chin 319 

IIG.  Passage  of  the  Head  through  the  Kxternal  Parts  in  Face  Presentation     .    .  820 

117.  Illustrating  the  Position  of  the  Head  when  Forward  Kotati(jn  of  the  Chin 

does  not  take  place 321 

118.  Dorso-anterior  Presentation  of  the  Arm 329 

119.  Dorso-posterior  Presentation  of  the  Arm 329 

120.  Spontaneous  Evolution.     (After  Chiara.) 334 

121.  Dorsal  Displacement  of  the  Arm 337 

122.  Dorsal  Displacement  of  the  Arm  in  Footling  Presentation.     (After  Barnes.)  337 

123.  Prolapse  of  the  Umbilical  Cord 838 

124.  Postural  Treatment  of  Prolapse  of  the  Cord 340 

125.  Braun's  Apparatus  for  Replacing  the  Cord 341 

126.  Labor  Complicated  by  Ovarian  Tumor 365 

127.  Twin  Pregnancy,  Breech  and  Head  Presenting 370 

128.  Head  Locking,  both  Children  preseniing  Head  first,     (.\fter  Barnes.)  .    .    .  372 

129.  Head  Locking,  first  Child  coming  Feet  first:    Impaction  of  Heads  from 

wedging  in  Brim.     (After  Barnes.) 373 

130.  Labor  impeded  by  Hydrocephalus 378 

131.  Adult  Pelvis  retaining  its  Infantile  Type 385 

132.  Scolio-Rachitic  Pelvis " 386 

133.  Rickety  Pelvis,  with  Backward  Depression  of  .Symphysis  Pubis 387 

134.  Flatness  of  Sacrum,  with  Narrowing  of  Pelvic  Cavity 388 

135.  Pelvis  Deformed  by  Spondyl-olisthesis.     (After  Kilian.) 388 

136.  [Spondyl-olisthesis.     (After  Neugebauer.)] 389 

137.  Osteomalacic  Pelvis 391 

138.  Extreme  Degree  of  Osteomalacic  Deformity 391 

139.  Obliquely-Contracted  Pelvis.     (After  Duncan.) 392 

140.  Kyphotic  Pelvis 393 

141.  Robert's,  or  Double  Obliquely-Contracted  Pelvis.     (After  Duncan.)  ....  393 

142.  Bony  Growth  from  Sacrum  obstructing  the  Pelvic  Cavity 394 

143.  Head  passing  through  the  Inlet  in  Flat  Pelvis.     (After  Parvin.) 397 

144.  Marked  Flexion  of  the  Head  entering  a  Generally-Contracted  Pelvis.  (After 

Parvin.) 397 

145.  Greenhalgh's  Pelvimeter 399 

146.  Section  of  Foetal  Cranium,  showing  its  Conical  Form 402 

147.  Showing  the    Greater  Breadth  of  the  Biparietal  Diameter  of  the  Fojtal 

Cranium.     (After  Simp.son.) 402 

148.  Showing  the  Greater  Space  for  the  Biparietal  Diameter  at  the  side  of  the 

Pelvis  in  certain  Cases  of  Deformity.     (After  Simpson.) 403 

149.  Irregular  Contraction  of  the  Uterus,  with  Encystment  of  the  Placenta  .    .    .  425 

150.  Illustrating  the   Dangerous  Thinning  of  the  Lower   Segment  of  Uterus, 

owing  to  Non-descent  of  Head  in  a  ca,se  of  Intra-uterine  Hydrocephalus. 

(After  Bandl.) 441 

151.  Partial  Inversion  of  the  Fundus 450 

152.  Illustrating  the  Commencement  of  Inversion  at  the  Cervix.    (After  Duncan.)  452 

153.  Barnes  Bag  for  Dilating  the  Cervix 460 

154.  Finst  Stage  of  Bii)ohir  Version.     (After  Barnes.) •  470 

155.  Second  Stage  of  Bipolar  Version.     (After  Barnes.) 471 

156.  Third  Stage  of  Bipolar  Version.     (After  Barnes.) 471 

157.  Fourth  Stage  of  Bipolar  Version.     (After  Barnes.) 472 

158.  Seizure  of  the  Feet  when  the  Hand  is  Introduced  into  the  Uterus     ....  473 


ILLUSTRATIONS.  XXV 

ITG-  PAGK 

159.  Drawing  Down  of  the  Feet  and  Completion  of  Version 474 

160.  Showing  tlie  Completion  of  Version.     (After  Barnes.) 475 

IGl.  Sijowing  tlie  use  of  the  Right  Hand  in  Abdomino-anterior  Positions     .    .    .  476 

162.  Denman's  Short  P'orceps 479 

163.  Ziegler's  Forceps 4g0 

164.  Simpson's  Forceps 481 

165.  Tarnier's  Forceps 482 

166.  Simpson's  Axis-Traction  Forceps 483 

167.  Position  of  Patient  for  Forceps  Delivery,  and  Mode  of  Introducing   the 

Lower  Blade 486 

168.  Introduction  of  tlie  Upper  Blade 488 

169.  Forceps  in  Position;  Traction  in  the  Axis  of  the  Brim,  Downward   and 

Backward 488 

170.  Last  Stage  of  Extraction ;  the  Handles  of  the  Forceps  turned  Upward  to- 

ward the  Mother's  Abdomen 489 

171.  [Hodge  Forceps] 495 

172.  [Wallace  Forceps] 495 

173.  [Davis  Forceps] 495 

174.  [Elliott  Forceps] 496 

175.  [Sawyer  Forceps]      496 

176.  [Application  of  the  Forceps  at  the  Inferior  Strait] 498 

177.  [Application  of  the  Forceps  with  the  Head  at  the  Superior  Strait,  the  Left 

Blade  held  in  place  by  an  Assistant] 499 

178.  [Direction  of  the  Forceps  as  the  Head  is  being  Delivered] 500 

179.  Vectis  with  Hinged  Handle 502 

180.  Wilmot's  Fillet 503 

181.^ 

182.  I  Various  Forms  of  Perforators 505 

183.] 

Jff"  I   Crochets 506 

185.  ■• 

186.  Craniotomy  Forceps 507 

187.  Simpson's  Cranioclast 507 

188.  Hicks'  Cephalotribe 508 

^189.  Perforation  of  the  Skull 511 

190.  Foetal  Head  Crushed  by  Cephalotribe 514 

191.  Professor  Simpson's  Basilyst 515 

192.  [Meigs' Straight  Craniotomy  Forceps] 516 

193.  [Meigs'  Curved  Craniotomy  Force|)s] 516 

194.  jMethod  of  Transfusion  by  Aveling's  Apparatus 545 

195.  Shafer's  Canula  for  Immediate  Transfusion 546 

196.  Section  of  a  Uterine  Sinus  from  the  Placental  Site  Nine  Weeks  after  De- 

livery.    (After  Williams.) 556 

197.  Plan  of  Bedroom  with  LTnsanitary  Arrangements 608 

198.  Plan  of  Bedroom  and  Dressing-room  to  illustrate  Case  2 609 


199.1 

200. 

201. 

202.  j-  Temperature  Charts 

203. 

204.  I 

205.  J 


616 
617 
618 
619 
620 
621 
L623 

206.  Hayes'  Tube  for  Tntra-uterine  Injections      623 

207.  Temperature  Chart 624 


PLATE    I. 


Duodenum 


Stoin;icli 


Os  Pubiv 


BliuMer 


Clitoris 


SECrriOS   OK   a    frozen    TIODY    in    THK   last    month    of   PBEONANCy    (AFTEB    1.RAUNE),    ILl.VSTH ATlNrt   THE 
REI.AT10N8   OK  THE   I  TERUS  TO   THE  8URR01NDIN0    TARTS,    AND   THE   ATTITinE   OF   THE 

ko:ti-8,  which  is  lvino  in  the  second  cranial  position. 


PLATE    II 


Pancreas 


Stomacl: 


Ext.  Os  Uteri 


Liquor  Amnii 


SECTION    OF  A    ritOZEN   BODY   AT  THE   TERMINATION   OK   THE   FIRST   STAGF,   OF   LABOK    (AFTER    liRAUNE). 

THE   HAG   OF   MEMBRANES   IS   STILT.   UNBROKEN,    THE   rF.RVIX    IS    FILLY    DILATKI),  AXU 

THE    HEAD    (IN   THE   SECOND    POSITION)    IS    IN    THE   PELVIC    CAVITI  . 


THE 


SCIENCE   AND  PRACTICE 


MIDWIFERY. 


PART  I. 


ANATOMY  AND  PHYSIOLOGY  OF   THE   ORGANS 
CONCERNED  IN  PARTURITION. 


CHAPTER  I. 

ANATOMY  OF  THE  PELVIS. 

The  pelvis  is  the  bony  basin  situated  between  the  trunk  and  the 
lower  extremities.  To  the  obstetrician  its  study  is  of  paramount  im- 
portance, for  it  not  only  contains,  in  the  unimpregnated  state,  all  the 
organs  connected  with  the  function  of  reproduction,  but  through  its 
cavity  the  foetus  has  to  pass  in  the  process  of  parturition.  An  accurate 
knowledge,  therefore,  of  its  anatomical  formation  may  be  said  to  be  the 
very  alphabet  of  obstetrics,  without  which  no  one  can  practise  midwifery, 
either  with  satisfaction  to  himself  or  safety  to  his  patient. 

In  a  treatise  on  obstetrics,  however,  any  detailed  account  of  the  purely 
descriptive  anatomy  of  the  pelvis  woidd  be  out  of  place.  A  knowledge 
of  that  nuist  be  taken  for  granted,  and  it  is  only  necessary  to  refer  to 
those  points  which  have  a  more  or  less  direct  bearing  on  the  study  of 
its  obstetrical  relations. 

The  'pehis  is  formed  of  foiir  ,|Don.es.      On  either  side  are  the  ossal  m 
innominata,  joined  together  by  the  sacrum ;  to  the  inferior  extremity V 
of  the  sacrum  is  attached  the  coccyx,  which  is,  in  fact,  its  continuation. 

The  OS  innorainatum  (Fig.  1)  is  an  irregularly-shaped  bone  origi- 
nally formed  of  three  distinct  portions,  the  ilium,  the  ischium,  and  the 
pubes,  which( remain  separated  from  each  other  up  to  and  beyond  the 
period  of  puberty!  They  are  united  at  the  acetabulum  by  a  Y-shaped 
cartilaginous  junction,  whicli  does  not,  as  a  rule,  become  ossified  until 
about  the  twentietli  year.  The  consequence  is  that  the  pelvis,  during 
the  period  of  growth,  is  subject  to  the  action  of  various  mechanical 

3  33 


34  ORGANS  CONCERXKI)  IX  PARTURITION. 

influences  to  a  far  o-rcater  extent  than  in  adult  life;  and  these,  as  we 
.shall  j)i-esentlv  see,  have  an  iuiportant  elfeet  in  deterniininj^  the  form  of 
the  hones.  The  external  surface  and  borders  of  the  os  innonunatuin 
are  chiefly  of   obstetric   interest    ironi    giving    attachment  to  muscles, 

Fig.  1. 


Os  Innoniinatum. 


many  of  which  have  an  important  accessory  influence  on  parturition, 
such"  as  the  muscles  forming  the  abdominal  wall,  which  are  attached  to 
its  crest,  and  those  closing  ks  outlet  and  forming  the  perineum,  Avhich 
are  attached  to  the  tuberosity  of  the  ischium.  On  the  anterior  and 
posterior  extremities  of  the  crest  of  the  ilium  are  two  prominences  (the 
anterior  and  posterior  spinous  processes),  which  are  points  from  which 
certain  measurements  are  sometimes  taken.  The  internal  surface  of  the 
upper  fan-shaped  ])ortion  of  the  os  innoniinatum  gives  attachment  to 
the  iliacus  muscle,  and  contributes  to  the  support  of  the  abdominal  con- 
tents :  along  with  its  fellow  of  the  opposite  side  it  forms  the  Hihc  ])elvis^ 
The  false  is  separated  from  the  trjLe  pelyis  by  the  ilio-pectineal  line, 
which,  with  the  upper  margin  of  the  sacrum,  forms  the  brim  of  the 
peh'is.  This  is  of  special  obstetric  importance,  as  it  is  the  first  part  of 
the  pelvic  cavity  through  which  the  child  passes,  and  that  in  which 
osseous  deformities  are  "most  often  met  with.  At  one  portion  of  the 
ilio-pectineal  line,  corresponding  with  the  junction  of  ilium  and  pubcs, 
is  situated  a  prominence  which  is  known  as  the  ilio-pectiueal, ^emi- 
nence. 

""  The  internal  smooth  surface  of  the  innominate  bone  below  the  Imea 
ilio-pectinea  forms  the  greater  portion  of  the  pelvis  proper.  In  front, 
wnth  the  corresponding  portions  of  the  opposite  bone,  it  forms  the  arch 
of  the  pubes,  under  which  the  head  of  the  child  i)asses  in  labor. 

Behind  this  we  observe  the  oval  obturator  foramen,  and  below  that 
the  tuberosity  and  spine  of  the  ischium,  the  latter  scjiarating  the  great- 
and  les.ser  sciatic  notches  and  giving  attachment  to  ligaments  of  import- 
ance. The  rouiih  articulating  surface  posteriorly,  by  which  the  junc- 
tion  with  the  sacrum   is  eflected,   may  be  noted,  and  above  *^Jiis  the 


ANATOMY  OF  THE  PELVIS. 


60 


prominence  to  which  tlie  powerful  ligaments  joining  the  sacrum  and 
OS  innominatum  are  attached. 

The  sacrum  (Fig.  2)  is  a  triangular  and  somewhat  spongy  bone 
forming  the  continuation  of  the  spmal  column  and  binding  together  the 
ossa    innominata.       It   is  originally  com- 
posed of  five  separate  portions,  analogous  ^^^-  2- 
to  the   vertebrae,  which  ossify  and  (unite 
about  the   period  of  puberty)  leaving  on 
its  internal  surface  four  prominent  ridges 
at  the  points  of  junction.     The  upper  of 
these  is  sometimes  so  well  marked  as  to  be 
mistaken,  on  vaginal  examination,  for  the 
projnontory  of  the  sacrum  itself. 

The  base  of  the  sacrum  is  about  4| 
iuch^s_iu.  width,  and  its  sides  rapidly  ap- 
proximate until  they  nearly  meet  at  its 
apex,  giving  the  whole  bone  a  triangular 
or  wedge  shape.  The  anterior  and  pos- 
terior surfaces  also  approximate  in  the 
same  way,  so  that  the  bone  is  much 
thicker    at    the    base    than    at  the  apex. 

The  sacrum,  in  the  erect  position  of  the  sacrum  and  coccyx. 

body,  is  directed  from  above  downward 

and  from  before  backward.  At  its  upper  edge  it  is  joined,  the  lumbo- 
sacral cartilage  intervening,  with  the  fifth  lumbar  vertebra.  The  point 
of  junction,  called  the  promontory  of  the  sacrum,  is  of  great  import- 
ance, as  on  its  undue  projection  many  deformities  of  the  brim  of  the 
pelvis  depend.  The  anterior  surface  of  the  bone  is  concave  and 
forms  the  curve  of  the  sacrum,  more  marked  in  some  cases  than 
in  others.  There  is  also  more  or  less  concavity  from  side  to  side.  On 
it  we  observe  four  apertures  on  each  side,  the  intervertebral  foramina, 
giving  exit  to  nerves.  The  posterior  surface  is  convex,  rough  and  irreg- 
ular for  the  attachment  of  ligaments  and  muscles,  and  showing  a  ridge 
of  vertical  prominences  corresponding  to  the  spinous  processes  of  the 
vertebrse. 

The  sacrum  is  generally  described  as  forming  a  keystone  to  the  arch 
constituted  by  the  pelvic  bones,  and  transmitting  the  weight  of  the  body, 
in  consequence  of  its  wedge-like  shape,  in  a  direction  which  tends  to 
thrust  it  downward  and  backward,  as  if  separating  the  ossa  innomi- 
nata. Dr.  Duncan,^  however,  has  shown,  from  a  careful  consideration 
of  its  mechanical  relations,  that  it  should  rather  be  regarded  as  a  strong 
transverse  beam  curved  on  its  anterior  surface,  the  extremities  of  wdiich 
are  in  contact  with  the  corresponding  articular  surfiices  of  the  ossa 
innominata.  The  weight  of  the  body  is  thus  transmitted  to  the 
innominate  bones,  and  through  them  to  the  acetabula  and  the  femora 
(Fig.  3).  There  counter-pressure  is  applied,  and  the  result  is,  as  we 
shall  subsequently  see,  an  important  modifying  influence  on  the  develop- 
ment and  shape  of  the  pelvis. 

The  coccyx  (Fig.  2)  is  composed  of  four  small  separate  bones,  which 

^  Haearches  in  Obstetrics,  p.  67. 


36 


ORGANS  CONCERNED  IN  PARTURITION. 


eventually  luiite  into  one,  but  not  until  late  in  lile.  The  U[)|)ernio.st  of 
these  articuhitcs  witli  the  apex  of  the  saeruni.  On  its  posterior  surfaee 
are  two  .'^mall  eornua.  whieli  unite  with  correspond  in*:;  points  at  the  tip 
of  the  saeruni.  The  bones  of  the  eoceyx  ta})er  to  a  point.  To  it  are 
attached  various  nuiseles  "which  iiave  the  efleet  of  imparting  cousider- 


Fjg.  3. 


Section  of  Pelvis  and  Heads  of  Thigh-bones,  showing  the  suspensory  action  of  the  sacro-iliac 

ligaments.    (After  Wood.) 

able  mobility.  (  During  labor,  also,  it  yields  to  the  mechanical  pre.ssure 
of  the  presenting  part,  so  as  to  increase  the  autero-posterior  diameter 
of  tlie  pelvic  outlet  to  the  extent  of  an  inch  or  more.j 

If,  through  disease  or  accident,  as  sometimes  ha2)|)ens,  the  articidar 
cartilages  of  the  coccyx  become  prenuitnrely  ossified,  the  enlargement  of 
the  pelvic  outlet  during  labor  may  be  prevented,  and  considerable  difli- 
culty  may  thus  arise.  This  is  most  apt  to  happen  in  aged  primij)ar8e 
or  in  women  Avho  have  followed  sedentary  occupations;  and  not  infre- 
quently, under  such  circumstances,  the  bone  fractures  under  the  pressure 
to  which  it  is  subjected  by  the  presenting  part. 

Pelvic  Articulations. — The  pelvic  bones  are  firmly  joined  together 
by  various  articulations  and  ligaments.  The  latter  are  arranged  so  as  to 
comj)lete  the  canal  through  which  the  foetus  has  to  pass,  and  which  is 
in  great  part  formed  by  the  bones.  On  its  interual^imtace,  M'here  the 
absence  of  obstruction  is  of  importance,  they  are  every  way  smooth  ; 
while  externaljj,  where  strength  is  the  desideratum,  they  are  arranged 
in  larger  masses,  so  as  to  unite  the  bones  firmly  together.  The  ])elvic 
articulations  have  been  generally  described  as  symphyses  or  amphiar- 
throdia — a  term  which  is  pro))erly  a])plied  to  two  articulatilig  surfaces 
united  by  fibrous  tissue  in  such  a  way  as  to  prevent  any  sliding  motion. 
It  is  certain,  however,  tliat  this  is  not  the  case  with  the  joints  of  the 


ANATOMY  OF  THE  PELVIS.  37 

female  pelvis  during  pregnancy  and  parturition.  Lenoir  found  that  in 
22  females  between  the  ages  of"  eighteen  and  thirty-five  there  was  a  dis- 
tinct sliding  motion,  (riierefore,  the  pelvic  articulations  are,  strictly 
speaking,  to  be  considered  examples  of  the  class  of  joints  termed 
arthrodia. 

Lunibo -sacral  Joint. — The  last  lumbar  vertebra  is  united  to  the 
sacrum  by  ligamentous  union  similar  to  that  which  joins  the  vertebrae 
to  each  other.  The  intervening  fibro-cartilage  forms  a  disk  which  is 
thicker  in  front  than  behind,  and  tliis,  in  connection  with  a  similar 
peculiarity  of  the  fifth  lumbar  vertebra,  tends  to  increase  the  sloped 
position  of  the  sacrum  and  the  angle  which  it  forms  with  the  vertebral 
column.  It  constitutes  the  most  prominent  portion  of  the  promontory 
of  the  sacrum,  and  is  the  part  on  which  the  finger  generally  impinges 
in  vaginal  examinations.  The  anterior  common  vertebral  ligament 
passes  over  the  surface  of  the  joints,  and  we  also  find  the  liganienta 
sulifl,aya  and  the  interspinous  ligaments,  as  in  the  other  vertebrte.  The 
articular  processes  are  joined  together  by  a  fibrous  capsule,  and  there 
is  also  a  peculiar  ligament,  the  kmibo-sacral,  extending  from  the  trans- 
verse process  of  the  vertebra  on  eacli  sTcIe,  and  attaching  itself  to  the 
sides  of  the  sacrum  and  the  sacro-iliac  synchondroses. 

Ligaments  of  Coccyx. — The  sacrum  is  joined  to  the  coccyx,  and, 
in  some  cases  at  least,  the  separate  bones  of  the  coccyx  to  each  other,  by 
small  cartilaginous  disks  like  that  connecting  the  sacrum  with  the  last 
lumbar  vertebra.  They  are  further  united  by  anterior  and  posterior 
common  ligaments,  the  latter  being  much  the  thicker  and  more  marked. 
In  the  adult  female  a  syiioyial  membrane  is  found  between  the  sacrum 
and  coccyx,  and  it  is  supposed  that  tliis  is  formed  under  the  influence 
of  the  movements  of  the  bones  on  each  other. 

Sacro-iliac  Synchondrosis. — The  opposing  articular  surfaces  of  the 
sacrum  and  ilium  are  each  coverecl^b^  cartilages,  that  of  the  sacrum 
being  the  thicker.  These  are  firmTy  united^  but  in  the  female,  accord- 
ing to  Mr.  Wood,^  they  are  always  more  or  less  separated  by  an  inter- 
veniiig  synovial  membrane.  Posterior  to  these  cartilaginous  convex 
surfaces  there  are  strong  mterosseous  ligaments  passing  directly  from 
bone  to  bone,  filling  up  the  interspace  between  them  and  uniting  them 
firmly.  There  are  also  accessory  ligaments,  such  as  the  siiperior  and 
anterior  sacro-iliac,  which  are  of  secondary  consequence.  The  posterior 
sacro-iliac  liganients,  however,  are  of  great  obstetric  importance.  They 
are  the  very  strong  attachments  which  unite  the  rough  surfaces  on  the 
posterior  iliac  tuberosities  to  the  posterior  and  lateral  surfaces  of  the 
sacrum.  They  pass  obliquely  downward  from  the  former  points,  and 
suspend,  as  it  were,  the  sacrum  from  them.  According  to  Duncan,  the 
sacrum  has  nothing  to  prevent  its  being  depressed  by  the  weight  of  the 
body  but  these  ligaments,  and  it  is  mainly  through  them  that  the  weight 
of  the  body  is  transmitted  to  the  sacro-cotyloid  beams  and  the  heads  of 
the  femora. 

The  sacro-sciatic  lig-aments  arc  instrumental  in  completing  the 
canal  of  the  pelvis.  The  greater  sacro-sciatic  ligament  is  attached  by  a 
broad  base  to  the  posterior- iulei-lur  spine  of  the  ilium,  and  to  the  pos- 

'  Todd's  Oydopcedia  of  Anatomy  and  Physiology,  article  "Pelvis,"  p.  123. 


38  OEGAyS  COyCERXEI)  IN  PARTl'lUTlON. 

terior  surfaces  of  tlic  sacrum  aud  coccyx.  Its  fibres  uuite  into  a  thick 
cord,  cross  each  other  in  an  X-like  manner,  and  again  expand  at  their 
insertion  into  the  tnberosity  of  the  ischium.  The  lesser  sacro-sciatic 
ligament  is  also  attached  \\ith  the  former  to  the  back  })arts  of  the  sacrum 
and  COCCYX,  its  fibres  passing  to  their  nuich  narrower  insertion  at  the 
spine  of  the  ischium,  and  converting  the  sacro-sciatic  notch  into  a  com- 
plete foramen. 

The  obturator  membrane  is  the  fibrous  aponeurosis  that  closes  the 
large  obturator  foramen.  Joulin^  supposes  that,  along  with  the  sacro- 
sciatic  ligaments,  it  may,  by  yielding  somewhat  to  the  ju'cssure  of  the 
fcetal  head,  tend  to  prevent  the  contusion  to  which  the  soft  parts  would 
be  subjected  if  they  were  compressed  between  two  entirely  osseous  sur- 
faces. 

S3maphysis  Pubis. — The  junction  of  the  pubic  bones  in  front  is 
eff'ccted  l)y  means  of  two  oval  plates  of  fibro-cartilage  attached  to  each 
articular  surface  by  nij)ple-shaped  projections,  which  fit  into  correspond- 
ing depressions  in  the  bones.  There  is  a  greater  separation  between  the 
bones  in  front  than  behind,  where  the  numerous  fibres  of  the  cartilagi- 
nous plates  intersect  aud  unite  the  bones  firmly  together.  At  the  upper 
and  back  part  of  the  articulation  there  is  an  interspace  between  the  car- 
tilages which  is  lined  by  a  delicate  membrane.  In  pregnancy  this  sj)ace 
often  increases  in  size,  so  as  to  extend  even  to  the  front  of  the  joint. 
The  juncture  is  further  strengthened  by  four  ligaments — the  anterior, 
the  posterior,  the  superior,  and  the  subpubic.  Of  these,  the  last  is  the 
largest,  connecting  together  the  }>ubic  bones  aud  forming  the  upper 
boundary  of  the  pubic  arch. 

Movements  of  Pelvic  Joints. — The  close  apposition  of  the  bones 
of  the  pelvis  might  not  unreasonably  lead  to  the  supposition  that  no 
movement  took  place  between  its  component  parts;  and  this  is  the 
opinion  which  is  even  yet  held  by  many  anatomists.  It  is  tolerably 
certain,  however,  that  even  in  the  unimpregnated  condition  there  is  a 
certain  amount  of  mobility.  I  Thus,  Zaglas  has  pointed  out"  that  in  man 
there  is  a  movement  in  an  antero-posterior  direction  of  the  sacro-iliac 
joints  which  has  the  effect,  in  certain  positions  of  the  body,  of  causing 
the  sacrum  to  project  downward  to  the  extent  of  about  a  line,  thus 
narrowing  the  pelvic  brim,  tilting  up  the  point  of  the  bone,  and 
thereby  enlarging  the  outlet  of  the  pelvis.  This  movement  seems 
habitually  brought  into  ])\\xy  in  the  act  of  straining  during  defeca- 
tion. 

During  pregnancy  in  some  of  the  lower  animals  there  is  a  very 
marked  movement  of  the  pelvic  articulations  which  materially  facili- 
tates the  process  of  ])arturition.  This,  in  the  case  of  the  guinea-])ig 
and  cow,  has  been  especially  jiointed  out  by  Dr.  Matthews  Duncan.^ 
In  the  former,  during  labor,  the  pelvic  bones  sej^arate  from  each  other 
to  the  extent  of  an  inch  or  more.  In  the  latter  the  movements  are 
different,  for  the  sym])hysis  j)ubis  is  fixed  by  bony  ankylosis,  and  is  im- 
movable;  but  the  sacro-iliac  joints  become  swollen  during  pregnancy, 

'  Traite  d'Accoxichements,  p.  11. 

^  Manthly  Journal  of  Medical  Science,  Sept.,  1851. 

^  Researches  m  Obstetrics,  p.  19. 


ANATOMY  OF  THE  PELVIS.  39 

and  extensive  movements  in  an  antero-posterior  direction  take  place  in 
them  which  materially  enlarge  the  pelvic  canal  during  lahor, 

fit  is  extremely  probable  that  similar  movements  take  place  in 
women,  both  in  'the  symphysis  pubis  and  in  the  sacro-iliac  joints, 
although  to  a  less  marked  extent.  |  These  are  particularly  well 
described  by  Dr.  Duncan.  They  seem  to  consist  chiefly  in  an  ele- 
vation and  depression  of  the  symphysis  pubis,  either  by  the  ilia 
moving  on  the  sacrum,  or  by  the  sacrum  itself  undergoing  a  forward 
movement  on  an  imaginary  transverse  axis  passing  through  it,  thus 
lessening  the  pelvic  l)rim  to  the  extent  of  one  or  even  two  lines,  and 
increasing,  at  the  same  time,  the  diameter  of  the  outlet  by  tilting  up 
the  apex  of  the  sacrum.  These  movements  are  only  an  exaggeration  of 
those  which  Zaglas  describes  as  occurring  normally  during  defecation. 
The  instinctive  positions  which  the  parturient  woman  assumes  find  an 
ex[)]anation  in  these  observations.  During  the  first  stage  of  labor, 
when  the  head  is  passing  through  the  brim,  she  sits  or  stands  or  walks 
about,  and  in  these  erect  positions  the  symphysis  pubis  is  depressed  and 
the  brim  of  the  pelvis  enlarged  to  its  utmost.  As  the  head  advances 
through  the  cavity  of  the  pelvis  she  can  no  longer  maintain  her  erect 
position,  and  she  lies  down  and  bends  her  body  forward,  which  has  the 
effect  of  causing  a  nutatory  motion  of  the  sacrum,  with  corresponding 
tilting  up  of  its  apex,  and  an  enlargement  of  the  outlet. 

These  movements  during  parturition  are  facilitated  by  the  changes 
which  are  known  to  take  place  in  the  pelvic  articulations  during  preg- 
nancy. /  The  ligaments  and  cartilages  become  swollen  and  softened, 
and  the  synovial  membranes  existing  betw^een  the  articulating  siirfaces 
become  greatly  augmented  in  size  and  distended  with  fluid.)  These 
changes  act  by  forcing  the  bones  apart,  as  the  swelling  of  a  sponge 
placed  between  them  might  do  after  it  had  imbibed  moisture.  The 
reality  of  these  alterations  receives  a  clinical  illustration  from  those 
cases  which  are  far  from  uncommon  in  which  these  changes  are  carried 
to  so  extreme  an  extent  that  the  power  of  progression  is  materially 
interfered  with  for  a  considerable  time  after  delivery. 

On  looking  at  the  pelvis  as  a  whole  we  are  at  once  struck  w^ith  its 
division  into  the  true  and  false  pelvis.  The  latter  portion  (all  that  is 
above  the  brim  of  the  pelvis)  is  of  comparatively  little  obstetric 
importance,  except  in  giving  attachments  to  the  accessory  muscles  of 
parturition,  and  need  not  be  further  considered.  /The  brim  of  the  pel- 
vis is  a  heart-shaped  opening  bounded  by  the  sacrum  behind,  the  linea 
ilio-pectinea  on  either  side,  and  the  symphysis  of  the  pubes  in  front.)' 
All  below  it  forms  thgj3ayity,  which  is  bounded  by  the  hollow  of  the 
sacrum  behind,  by  the  inner  surfaces  of  the  innominate  bones  at  the^  , 
sides  and  in  front,  and  by  the  posterior  surface  of  the  symphysis  pubis.^*^ 
It  is  in  this  part  of  the  pelvis  that  the  changes  in  direction  which  the 
ftetal  head  undergoes  in  labor  are  im]")arted  to  it.  The  lower  border  of 
this  canal  or  pelvic  outlet  (Fig.  4)  is  lozenge-shaped — is  bounded  by  the 
ischiatic  tuberosities  on  either  side,  the  tip  of  the  coccyx  behind,  and 
the  under  surface  of  the  pubic  symphysis  in  front.  Posteriorly  to 
the  tuberosities  of  the  ischia  the  boundaries  of  the  outlet  are  com- 
pleted by  the  sacro-sciatic  ligaments. 


40 


ORdANS  CONCERNED  IN  PARTriUTION. 


There  is  a  very  markcHl  clittbrcnco  hotwccii  the  pelvis  in  llie  male 
aiul  the  ieniale,  and  the  j)eeuliaiitie.s  of  the  hitter  all  tend  to  facilitate  the 
process  of  j>artiiritiou.     In  the  female  pelvis  (Fig.  5)  all  the  boues  are 


Fig.  4. 


Outlet  of  Pelvis. 

i  lighter  m  structure,  and  have  the  points  for  muscular  attachments 
iiTUcITTess  developed.  The^lliac  boues  are  more  s})read  out,  hence  the 
greater  breadth  which  is  observed  in  the  female  figure,  and  the  peculiar 
side-to-side  movement  which  all  females  have  in  walking.  The 'tuber- 
osities of  the  ischia  are  lighter  in  structure  and  fartlier  ajDart,  and  the 

t^  rami  of  the  pubes  also  converge  at  a  much  less  acute  ang^e.  Tiiis 
greater  breadth  of  the  pubic  arch  gives  one  of  tlie  most  easily  appreciable 
points  of  contrast  between  the  male  and  the  female  pelvis :  the  pubic  arch 

Fig.  5. 


The  Female  Pelvis. 


in  the  female  forms  an  angle  of  from  90°  to  100°,  while  in  the  male 

(    (Fio-.  6)  it   averacres  from  70°  to  75°.     The  obturator  foramina  are 

p  more  triangular  in  shape 

\  "o  The  whole  cavity  of  t 


/ 


ity  of  the  female  pelvis  is  wider  and  less  funnel- 
shaped  than  in  the  'male,  the  symphysis  pubis  is  not  so  deep,  and,  as 
the  promontory  of  the  sacrum  does  not  project  so  much,  the  shape  of 


ANAT03IY  OF  THE  PELVIS. 


41 


<^lie  pelvic_brim  is_  more  oyal  tliiin  in  the  male.  These  differences 
between  the  male  and  female  pelvis  are  probably  due  to  the  presence 
of  the  female  genital  organs  in  the  true  pelvis,  the  growth  of  which 


Fig.  6. 


The  Male  Pelvis. 

increases  its  development  in  width.  In  proof  of  this,  Schroeder  states 
that  in  women  with  congenitally  defective  internal  organs,  and  in 
women  who  have  had  both  ovaries  removed  early  in  life,  the  f)elvis 
has  always  more  or  less  of  the  masculine  type. 

The  measurements  of  the  pelvis  that  are  of  most  importance 
from  an  obstetric  point  of  view  are  taken  between  various  points 
directly  opposite  to  each  other,  and  are  know^n  as  the  diameters  of  the 
l)elvis.  Those  of  the  true  pelvis  are  the  diameters  which  it  is  especi- 
ally important  to  fix  in  our  memories,  and  it  is  customary  to  describe 
three  in  works  on  obstetrics — the    antero-posterior  or  conjugate,    the 

Fig.  7. 


Brim  of  Pelvis,  showing  antero-posterior,  c.  v,  oblique,  d,  and  transverse,  t,  diameters. 

obliqiie,  and  the  transverse — although  of  course  the  measurements 
may  be  taken  at  any  opposing  points  in  the  circumference  of  the  bones. 
The  antero-posterior  (diameter  conjucjata  vera,  c,  Y,  sacro-pubic)  at  the 
brim  (Fig.  7)  is  taken  from  the  (^upper  part  of  the  posterior  surface  of 


42 


ORG  Ays  COyCERNED  AY  PARTVRITIOy. 


the  symphysis  pubis  to  the  centre  of  tlie  pioiuoiitory  of  tlie  sacrum;) 
in  the  ciivitv,  Ironi  the  centre  of  the;  symphysis  piil>is  to  a  correspond- 
ing point  in  the  hotly  of  the  tliird  })iecc  of  the  sacrum;  and  at  the 
outlet  (ct)ccy-pul)ic),  from  the  lower  l)order  of  the  symphysis  pul>nrto 
tlie  tip  of  the  coccyx.  The  ohlh^iv  (diameter  dkujondlis,  d),  at  the' 
hrnyi,  is  taken  from  the  sacro-iliac  joint  on  cither  side  to  a  point  (XTlie 
brim  c<trn'sj)ondin<r  with  the  ilio-pectincal  cniincnce  (that  >tartin<r  from 
the  right  sacro-iliac  joint  being  called  tlic  rigiit  ol)li(pie  [diameter  (I'khj- 
onalis  dextra,  i).  d],  that  from  the  left,  the  left  oblique  [diameter  dicuj- 
onuUs  sinistra,  D.  s]) ;  injlie  cavity  a  similar  measurement  is  made  at 
the  same  level  as  the  conjugate  ;  while  at  the  outlet  an  oblique  diameter 
is  not  usually  measured.  The  transverse  (diameter  transversa,  T)  is 
taken  at  the  brim,  from  a  point  midway  between  the  sacro-iliac  joint 

and  the  ilio-])ectineal  eminence  to  a 
YiQ,  8.  corresponding  point  at  the  opposite 

side  of  the  brim  ;  in  the  cavity 
from  points  in  the  same  plane  as 
the  conjugate  and  oblique  diam- 
eters; and  at  the  outlet  from  the 
centre  of  the  inner  border  of  one 
ischial  tuberosity  to  that  of  the 
other.  The  measurements  given  by 
various  wTiters  differ  considerably 
and  vary  somewhat  in  different 
pelves.  Taking  the  average  of  a 
large  number,  the  following  may 
be  given  as  the  standard  measure- 
ments of  the  female  pelvis : 


Brim  . 
llCavitv 
i  lOiulet 


Antero- 
posterior, 
C.V. 

4.7 


Oblique, 
I). 


•11 


Trans 

verge 

T 

in.X^/ 

5.2°  ' 
4.75  ' 
4  2 


It  will  be  observed  that  the 
lengths  of  the  corresponding  diam- 
eters at  different  places  vary 
greatly  ;  thus,  Avliilc  the  transverse 
(t)  is  longest  at  the  brim,  the 
oblique  (d)  is  longest  in  the  cav- 
itv,  and  the  antero-postcrior  at  the 
outlet.  It  will  be  subsequently 
seen  that  tiiis  fact  is  of  gi-cat  jirac- 
tical  imj)ortance  in  studying  the 
mechanism  of  delivery,  for  the 
head  in  its  descent  through  the 
])elvis  alters  its  position  in  such  a 
wav  as  to  ada])t  itself  to  the  longest 
tliameter  of  the  pelvis;  thus,  as  it 
passes   through    the   cavity  it  lies  in  the  oblique  (D)    diameter,    and 


Section  of  Pelvis,  showing  the  diameters. 


ANATOMY  OF  THE  PELVIS.  43 

then  rotates  so  as  to  be  expelled  in  the  antero-posterior  (c.  v)  diam- 
eter of  the  outlet. 

In  thinking  of  these  measurements  of  the  pelvis  it  must  not  be 
forgotten  that  they  are  taken  in  the  dried  bones,  and  that  they  are 
considerably  modified  during  life  by  the  soft  parts.  This  is  especi- 
ally the  case  at  the  brim,  where  the  projection  of  the  psoas  and 
iliacus  nniscles  lessens  the  transverse  (t)  diameter  about  half  an  inch, 
while  the  antero-posterior  (c.  v)  diameter  of  the  brim  and  all  the 
diameters  of  the  cavity  are  lessened  by  a  quarter  of  an  inch.  The 
right,  oblique  diameter  (d.  d)  of  the  brim  is,  even  in  the  dried  pelvis, 
found  to  be  on  an  average  slightly  longer  than  the  left  (d.  s),  probably 
on  account  of  the  increased  develojjment  of  the  right  side  of  the  })clvis 
from  the  greater  use  made  of  the  right  leg ;  but,  in  addition  to  this, 
the  left  oblique  diameter  (d.  s)  is  somewhat  lessened  during  life  by 
the  presence  of  the  rectum  on  the  left  side.  The  advantage  gained 
by  the  comparatively  frequent  passage  of  the  head  through  the  pel- 
vis in  the  right  oblique  diameter  (d.  d)  is  thus  explained. 

There  are  one  or  two  other  measurements  of  the  true  pelvis  which 
are  sometimes  given,  but  which  are  of  secondary  importance.     One  of 
these,  the  sacro-cotyloid  diameter,  is  that  between  the  promontory  of 
the   sacrum  and   a  point  immediately  above  the  cotyloid  cavity,  and 
averages  from  3.4  to  3.5  inches.     Another,  called  by  Wood  the  lower  or! 
inclined  conjugate  diameter  (diameter  conjuqata  diagonalis,  c.  d),  is  that  i  j 
between  the  centre  of  the  lower  margin  of  the  symphysis  pubis  and  1 1 
the  promontory  of  the  sacrum,  and  averages  half  an  inch  more  than  ' 
the  antero-posterior  diameter  of  the  brim.     These   measurements  are 
chiefly  of  importance  in  relation  to  certain  pelvic  deformities. 

The  external  measurements  of  the  pelvis  are  of  no  real  consequence 
in  normal  parturition,  but  they  may  help  us  in  certain  cases  to  estimate 
the  existence  and  amount  of  deformities.     Those  which  are  generally  i 

given    are:  Between the   anterior-superior    iliac    spines,    10    inches;! 

between  the  central  points  of  the  crests  of  the  ilia,  10-|  inches; 
between  the  (spinous  process  of  the  last  lumbar  vertebra  and  the 
upper  part  of  the  symphysis  pubis  (external  conjugate),  7  inches  J      r-*.,^ 

Planes  of  the  Pelvis.— By  the  planes  of  the  pelvis  are  meant  "^^^ 
imaginary  levels  at  any  portion  of  its  circumference.  If  we  were  to 
cut  out  a  piece  of  cardboard  so  as  to  fit  the  pelvic  cavity,  and  place  it 
either  at  the  brim  or  elsewhere,  it  would  represent  the  pelvic  plane  at 
that  particular  part ;  and  it  is  obvious  that  we  may  conceive  as  many  ,  . 
planes  as  we  desire.  Observation  of  the  angle  which  the  pelvic  planes  y  \. 
form  with  the  horizon  shows  the  great  obliquity  at  which  the  pelvis  is 
placed  in  regard  to  the  spinal  column.  Thus  the  angle  a  b  i  (Fig.  9) 
represents'  the  inclination  to  the  horizon  of  the  plane  of  the  pelvic 
brim,  i  B,'and  is  estimated  to  be  about  (3p'),(while  the  au^le  which  the 
same  plane  forms  with  the  vertebral  colimm  is  about  150^  {The  plane 
of  the  outlet  forms,  with  .the  coccyx  in  its  usual  position^  an  angle  with 
the  horizon  of  about  11°;  but  which  varies  greatly  with  the  movements 
of  the  tip  of  the  coccyx  and  the  degree  to  which  it  is  pushed  back 
during  parturition.  These  figures  must  only  be  taken  as  giving  an 
approximate  idea  of  the  inclination  of  the  pelvis  to  the   spinal    col- 


\ 


A 


44 


OROANS  C'ONCi:nyi:i>  ix  partviutios. 


unm,  ami  it  must  be  rcmciiilx'icd  that  tlie  (lc<;ree  ot"  inclination  varies 
considerably  in  the  same  female  at  (liU'crenl  times,  in  accordance  with 
the  ])osition  of  the  body.  Durinjr  ])i'('onancy  especially  the  obliijuitv 
of  tlie  brim  is  lessened  by  the  patient    throwing  herself  backward   in 


Planes  of  the  Pelvis,  -with  Horizon. 

A  B.     Horizon.  c  d.     Vertical  line. 

A  B  I.     Anple  of  inclination  of  pelvis  to  horizon,  equal  to  60°. 

B  I  c.     Angle  of  inclination  of  pelvis  to  si)inal  column,  ecjiial  to  150°. 

c  I  J.     Angle  of  inclination  of  sacrum  to  spinal  column,  equal  to  130°. 

F,  F.     Axis  of  pelvic  inlet.  L  M.     Mid-plane  iu  the  middle  line. 

N.    Lowest  point  of  mid-plane  of  ischium. 

order  to  support  more  easily  the  weight  of  the  graviil  uterus.  The 
height  of  the  promontory  of  the  sacrum  above  the  ujijier  margin  of 
the  symphysis  jnibis  is  on  au  average  about  3|-  inches,  and  a  line  pass- 
ing horizontally  backward  from  the  latter  ]>oint  would  impinge  on  the 
junction  of  the  .second  and  third  coccygeal  bones. 

Axes  of  the  Parturient  Canal. — Vyy  the  axis  of  the  pelvis  is 
meant  an  imaginary  line  which  indicates  tlu^  direction  which  the  foetus 
takes  during  its  expulsion.  (The  axis  of  the  brim  (Fig.  10)  is  a  line  1 1 
drawn  perpendicular  to  its  plane,  which  would  extend  from  the  unibil- j ' 
icus  to  about  the  a])ex  of  the  coccyx  ;)  ^hc  axis  of  the  outlet  of  the  liouy 
pelvis  intersects  this,  and  extends  from  the  centre  of  the  ]iromontorv  of 
the  .«acrum  to  midway  between  the  tuberosities  of  the  i.schia.)  The  axis 
of  the  entire  jielvic  canal  is  re])re.sented  by  the  .sum  of  the  axes  of  au 
indcHnite  number  of  jilanes  at  different  levels  of  the  pelvic  cavity, 
which  forms  an  irrcfjular  parabolic  line,  as  represented  in  the  accom- 
panying diagram  (Fig.  10,  a  d). 

It  must  be  borne  in  mind,  however,  that  it  is  not  the  axis  of  the  bony 
pelvis  alone  that  is  of  importance  in  obstetrics.     Wc  must  always,  in 


ANATOMY  OF  THE  PELVIS. 

Fig.  10. 


46 


Axes  of  the  Pelvis. 

A.    Axis  of  superior  plane.  b.     Axis  of  niiJ-plane. 

D.    Axis  of  canal. 


c.     Axis  of  inferior  plane. 
E.     Horizon. 


considering  this  subject,  remember  that  the  general  axis  of  the  parturi- 
ent canal  (Fig.  11)  also  includes  that  of  the  uterine  cavity  above  and 
of  the  soft  parts  below.     These  are  variable  in  direction  according  to 


Fig.  11. 


Representing  General  Axis  of  Parturient  Canal,  including  the  Uterine  Cavity  and  Soft  Parts. 


46 


ORGAXS  CONCERNED  IN  PARTrniTION. 


Fig.  12. 


circiiin.stan('cs ;  aiulfit  is  (Hily  tlic  axis  (if  that  |><trti(»n  of  tlit-  par- 
turient canal  extend injji;  lu'twcoii  the  plane  oi'  the  pelvic  hrini  and 
a  plane  between  the  lower  edjjje  of  the  pubic  syin]>liysis  and  the 
base  of  the  coccyx  that  is  fixed.!  The  axis  of  the  lower  part  of  the 
canal  will  vary  accordintji;  to  the  amount  of  distension  oi"  the  jierinenni 
during;-  labor;  but  when  this  is  stretched  to  its  ntino>t,  just  before  the 
expidsion  of  the  head,  the  axis  of  the  ])lane  between  the  edge  of  the 
distended  perineum  and  the  lower  border  of  the  symphysis  looks  ncai-lv 
directly  forward.  The  axis  of  the  uterine  cavity  oenci-ally  corresjionds 
with  that  of  the  pelvic  brim,  but  it  may  be  much  altered  by  abnormal 
jtositions  of  the  uterus,  such  as  anteversion  irom  hixity  of  liie  abd<inii- 
nal  walls.  The  f(etus,  under  such  circumstances,  will  not  enter  the 
brim  in  its  proper  axis,  and  ditKculties  in  the  labor  arise.  A  know- 
ledge of  the  general  direction  of  the  parturient  canal  is  of  great  import- 
ance in  ])ractieal  midwifery  in  guiding  us  to  the  introduction  of  the 
hand  or  instruments  in  obstetric  operations,  and  in  showijig  us  Iuav  to 
obviate  difficidties  arising  from  such  accidental  deviations  of  the  uterus 
as  have  just  been  alluded  to. 

Cavity  of  the  Pelvis. — The  arrangements  of  the  ])ones  in  tlie 
interior  of  the  pelvic  canal  (Fig.  12)  are  important  in  relation  to  the 
mechanism  of  delivery.      A  line   ])a.ssing   between  the  spine  of  the 

ischium  and  the  ilio-pectincal  emi- 
nence divides  the  imicr  surface  of  the 
ischial  bone  into  two  smooth  ])lane  sur- 
faces, which  have  received  the  Jiame  of 
the  planes  of  the  ischium.  Two  other 
planes  are  formed  by  the  inner  surfaces 
of  the  })ubic  bones  in  fi-ont  and  by  the 
U])])er  ])ortion  of  the  sacrum  behind, 
both  having  a  direction  dowuMaixl  and 
backward.  In  studying  the  mechanism 
of  delivery  it  will  be  seen  that  many 
obstetricians  attribute  to  these  ])lanes, 
in  conjunction  with  the  spines  of  the 
ischia,  a  very  im])ortant  influence  in 
effecting  rotation  of  the  foetal  head 
from  the  oblique  to  the  antcro-pos- 
terior  diameter  of  the  pelvis. 
Development  of  the  Pelvis. — The  })cculiaritics  of  the  jielvis  during 
inlluKv  and  cliildliood  are  of  interest  as  leading  to  a  knowledge  of  the 
manner  in  which  the  form  observed  during  adult  life  is  imjiressed  ujion 
it.  The  .sacrum  in  the  i>elvis  of  the  child  (Fi^.  1'3)  is  less  devcli^ied 
transversely  and  is  much  less  deeph^  curved  tliali  m  tTie  adult.  The 
pubes  is  also  much  shorter  from  side  to  side,  and  the  ]^ul)ie  arch  is  an 
acute  angle.  The  result  of  this  narrowness  of  both  the  pid)es  and 
sacrum  is  that  the  transverse  (t)  diameter_of  thejieh'ic^  brim  is 
shorter  instead  of  longer  than  the  antero-po.sterior  (c.  v).  The  sitles 
of  the  pelvis  have  a  tendency  to  jiarallelism,  as  well  as  the  antero-j)os- 
terior  walls;  and  this  is  .stated  by  Wood  to  be  a  ])eculiar  characteristic 
of  the  infantile  pelvi.s.     The  iliac  boues  are  not  spread  out  as  in  adult 


Side  View  of  Pelvis. 


ANATOMY   OF  THE  PELVIS. 


47 


life,  so  that  the  centres  of  the  crests  of  the  ilia  are  not  more  distant 
from  each  other  than  the  anterior  superior  spines.  Tiie  cavity  oi'  the 
true  pelvis  is  small,  and  the  tuberosities  of  the  ischia  are  j)ro[)ortionately 
nearer  to  each  other  than  they  afterward  become;  the  pelvic  viscera  are 
consequently  crowded  np  into  the  abdominal  cavity,  which  is,  for  this 
reason,  much  more  prominent  in  children  than  in  adults.     The  bones 

Fi(i.  13. 


Pelvis  of  a  Child. 


are  soft  and  semi -cartilaginous  until  after  the  period  of  puberty,  and 
yield  readily  to  the  mechanical  influences  to  which  they  are  subjected  ; 
and  the  three  divisions  of  the  innominate  bone  remain  separate  until 
about  the  twentieth  year. 

As  the  child  grows  older  the  transverse  development  of  the  sacrum 
increases,  and  the  pelvis  begins  to  assume  more  and  more  of  the  adult 
shape.  The  mere  growth  of  the  bones,  however,  is  not  sufficient  to 
account  for  the  change  in  the  shape  of  the  pelvis,  and  it  has  been  well 
shown  by  Duncan  that  this  is  chiefly  produced  by  the  pressure  to  which 
the  bones  are  subjected  during  early  life.  The  iliac  bones  are  acted 
upon  by  two  principal  and  opposing  forces.  One  is  the  weight  of  the 
body  aliove,  which  acts  vertically  upon  the  sacral  extremity  of  the  iliac 
beam  through  the  strong  posterior  sacro-iliac  ligaments,  and  tends  to 
throw  the  lower  or  acetabular  ends  of  the  sacro-cotyloid  beams  outward. 
This  outward  displacement,  however,  is  resisted,  partly  by  the  junction 
between  the  two  acetabular  ends  at  the  front  of  the  pelvis,  but  chiefly 
by  the  opposing  force,  which  is  the  upward  pressure  of  the  lower  ex- 
tremities through  the  femurs.  Tiie  result  of  these  counteracting  forces 
is  that  the  still  soft  bones  bend  near  their  junction  with  the  sacrum,  and 
thus  the  greater  transverse  development  of  the  pelvic  brim  character- 
istic of  adult  life  is  established.  In  treating  the  pelvic  deformities  it 
will  be  seen  that  the  same  forces  applied  to  diseased  and  softened  bones 
explain  the  ])eculiarities  of  form  that  they  assume. 

Pelvis  in  Different  Races. — The  researches  that  have  been  made  on 
the  differences  of  the  ]>elvis  in  different  races  prove  that  those  are  not  so 
great  as  might  have  been  expected.     Joulin  pointed  out  that  in  all 


48  ORCiAys  coycKRM:i>  l\  rAnrrniTioy. 

luunan  jk'Ivcs  the  tniiisviTsc  (t)  diaiuctcr  was  larger  than  tho  aiitcro- 
postcrioi-  (c.  v),  \\\\\\v  the  rovcrsc  was  the  case  in  all  tlie  lower  animals, 
even  in  the  higiiest  siniia-,  Tiiis  observation  has  been  more  reeentlv 
confirmed  by  Von  Franqiie,'  who  has  made  careful  measurements  of  the 
pelvis  in  various  races.  Jn  the  pelvis  of  tlie  jijorilla  the  oval  form  of 
the  l)rim,  resulting  from  the  increased  lenirth  of  the  conjugate  (c.  \) 
diameter,  is  very  marked.  In  certain  races  tliere  is  so  far  a  tendency 
to  animality  of  type  that  the  diilerence  between  the  transverse  (t)  and 
conjugate  (c.  v)  diameters  is  much  less  than  in  Euro^jean  women,  but  it 
is  not  sufficiently  marked  to  enable  us  to  refer  any  given  pelvis  to  a 
particular  race.  Von  Franque  makes  the  general  observation  that  the 
size  of  the  pelvis  increases  from  south  to  north,  but  that  the  conjugate 
(c.  v)  diameter  increases  in  projiortion  to  the  transverse  (t)  in  southern 
races. 

Soft  Parts  in  Connection  -with  Pelvis. — In  closing  the  descri])tiou 
of  the  pelvis  the  attention  of  the  student  must  be  directed  to  the  mus- 
cular and  other  structures  which  cover  it.  It  has  already  been  jiointed 
out  that  the  measurements  of  the  pelvic  diameters  are  considerably 
lessened  by  the  soft  parts,  which  also  influence  ])arturition  in  other 
ways.  Thus,  attached  to  the  crests  of  the  ilia  arc  strong  muscles 
which  not  only  support  the  enlarged  uterus  during  pregnancy,  but 
are  powerful  accessory  muscles  in  labor :  in  the  pelvic  cavity  are  the 
obturator  and  pyriformis  muscles  lining  it  on  either  side;  the  pelvic 
cellular  tissue  and  fascise ;  the  rectum  and  bladder ;  the  vessels  and 
nerv^es,  jiressure  on  which  often  gives  rise  to  cramps  and  pains  during 
pregnancy  and  labor;  while  beloAv  the  outlet  of  the  pelvis  is  closed  and 
its  axis  directed  forward  by  the  numerous  muscles  forming  the  floor  of 
the  pelvis  and  perineum.  The  structures  closing  the  pelvis  have  been 
accurately  described  by  Dr.  Berry  Hart,^  who  points  out  that  they  form 
a  complete  diajihragm  stretching  from  the  pelvis  to  the  sacrum,  in 
which  are  three  "faults"  or  *' slits"  formed  by  the  orifices  of  the 
urethra,  vagina,  and  rectum.  The  first  of  these  is  a  mere  capillary 
slit;  the  last  is  closed  by  a  strong  muscular  sphincter;  while  the  vagina, 
in  a  healthy  condition,  is  also  a  mere  slit,  with  its  Avails  in  accurate  ap- 
position.  Hence  it  follows  that  none  of  these  apertures  impairs  the 
structural  efficiency  of  the  pelvic  floor  or  the  support  it  gives  to  the 
structures  above  it. 

'  Soanzoni's  BeitrUge,  1867. 

'  The  Slrudnml  Anatomy  of  the  Female  Pelvic  Floor. 


THE  FEMALE  GENERATIVE  ORGANS.  49 


CHAPTER  II. 

THE  FEMALE  GENERATIVE  ORGANS. 

The  reproductive  organs  iu  the  female  are  conveniently  divided, 
a(!cordiug'  to  their  function,  into — 1.  The  external  or  copulative  organs, 
which  are  chiefly  concerned  in  the  act  of  insemination,  and  are  only  of 
secondary  importance  in  parturition  :  they  include  all  the  organs  situate 
externally  which  form  the  vulva,  and  the  vagina,  which  is  placed  inter- 
nally and  forms  the  canal  of  communication  between  the  uterus  and  the 
vulva ;  2.  The  internal  or  formative  organs :  they  include  the  ovaries, 
which  are' the  most  important  of  all,  as  being  those  in  which  the  ovule 
is  formed;  the  Fallopian  tubes,  through  which  the  ovule  is  carried  to 
the  uterus ;  and  the_jiteriis,  in  which  the  impregnated  ovule  is  lodged 
and  developed. 

1.  The  external  organs  consist  of — 

The  mons  Veneris  (Fig.  14, /'),  a  cushion  of  adijjose  and  fibrous 
tissue  which  forms  a  rounded  projection  at  the  upper  part  of  the  vulva. 
It  is  in  relation  above  with  the  lower  part  of  the  hypogastric  region, 
fi'om  which  it  is  often  separated  by  a  furrow,  and  below  it  is  continuous 
with  the  labia  majora  on  either  side.  It  lies  over  the  symphysis  and 
horizontal  rami  of  the  pubes.  After  puberty  it  is  covered  with  hair,  /v 
On  its  integument  are  found  the  openings  of  numerous  sweat  and  ^-\ 
sebaceous  glands. 

The  labia  majora  (Fig.  14,  a)  form  two  symmetrical  sides  to  the 
longitudinal  aperture  of  the  vulva.     They  have  two  surfaces — one  ex- 
ternal, of  ordinary  integument,  covered  with  hair;  and  another  internal, 
of  smooth   mucous  membrane,  in  apposition  with  the  corresponding 
portion  of  the  opposite  labium,  and  separated  from  the  external  sur- 
face by  a  free  convex  border.     They  ax'e  thicker  iu  front,  where  they    /' 
run  into  the  mons  Veneris,  and  thinner  behind,  where  they  are  united,  V^ 
in  front  of  the  perineum,  by  a  thin  fold  of  integument  called  the  four-'        h 
chette.  which  is  almost  invariably  ruptured  in  the  first  labor.     In  the    Ky 
virgin  the  labia  are  closely  in  apposition,  and  conceal  the  rest  of  the 
generative  organs.     After  childbearing  they  become  more  or  less  sepa- 
rated from  each  other,  and   in   the  aged  tliey  waste  and  the  internal 
nymphse  protrude  through  them.     Both  their  cutaneous  and  mucous  >\ 
surfaces  contain  a  large  number  of  sebaceous  glands,  opening  either      \ 
directly  on  the  surflace  or  into  the  hair-follicles.     In  structure  the  labia 
are  composed  of  connective  tissue,  containing  a  varying  amount  of  fat, 
and  parallel  with  their  external  surface  are  placed  tolerably  close  plex- 
uses of  elastic  tissue,  interspersed  with  regularly  arranged  smooth  mus- 
cular fibres.     These  fibres  are  described  by  Broca  as  forming  a  mem- 
branous sac,  resembling  the  dartos  of  the  scrotum,  to  which  the  labia 
majora  are  analogous.     Toward  its  upper  and  narrower  end  this  sac  is 
continuous  with  the  external  inguinal  ring,  and  iu  it  terminate  some  of 


50 


onn.ixs  ro.\ri:nxi:i)  ix  PARTcnrnox. 


the  fibres  of   the  round   lij^aim-iit.      J'lic  aiialoiry  with  tlic  srrotum  is 
lurtlier  borne  out   by  the  occasional  iiernial  jirotrusion  oi'  tlie  ovary      t 
into  the  labium,  correspoudiug  to  the  uonuai  desceut  ol"  the  testis  in    J^ 
the  male.  ^    Jv/s^Jw     C'C^.-A.^-^  cl  ^  V-"'^'^^^  r/ 

The  labia  minora,  or  nymphsB  (Fig.  14;  6),  ai-e  two  folds  of  mucous 
meml)rane,  comm('ncin*i-  below,  on  cither  side,  about  the  centre  ol  the 
iuternal  surface  of  the  labium  externum;  they  converge  a.s  they  proceed 

lUG.  14. 


External  Genitals  of  Virgin  with  Diaphragmatic  Hymen.    (After  Sappey.) 

a.  Lubium  mnjiis.    b.  Labium  miniiH.     c.  Prteputium  clitoridia.    d.  Glana  clitoridis. 
e.  Vestibule  just  above  urethral  orifice.    /.  Mona  Veneris. 

upward,  bifurcating  a.s  they  ajiproach  each  other.  The  lower  branch 
of  this  bifurcation  is  attached  to  the  clitoris  (Fig.  14,  c),  Avhile  the 
iip])er  and  larger  unites  with  its  fellow  of  the  opposite  side  and  forms  a 
fold  round  the  clitoris,  known  as  its  prepuce.  The  nym])ha>  are  usually 
entirely  concealed  by  the  labia  majora,  but  after  childl)earing  and  in  old 
age  they  project  somewhat  beyond  them  ;  then  they  lose  their  delicate 
pink  color  and  soft  texture,  and  become  brown,  dry,  and  like  skin  in 
appearance.  This  is  especially  the  case  in  some  of  the  negro  races,  in 
whom  thev  form  long  projecting  folds  callccl  the  a])ron. 

The  surfaces  of  the  nymplue  are  covered  with  tessellated  e})itheliura, 


THE  FEMALE  GENERATIVE  ORGANS.  51 

and  over  tlieiii  arc  distributed  a  large  number  of  vaseulai'  papillie, 
somewhat  enlarged  at  their  extremities,  and  sebaceous  glands,  which 
are  more  numerous  on  their  internal  surfaces.  The  latter  secrete  an 
odorous,  cheesy  matter  which  lubricates  the  surface  of  the  vulva  and 
prevents  its  folds  adhering  to  each  other.  The  nynipha?  are  composed 
of  trabecuhe  of  connective  tissue  containing  muscular  fibres. 

The  clitoris  (Fig.  14,  d)  is  a  small  erectile  tubercle  situated  about 
half  an  inch  below  the  anterioi'  commissure  of  the  labia  majora.  It  is 
the  analogue  of  the  penis  in  the  male,  and  is  similar  to  it  in  structure, 
consisting  of  two  corpora  cavernosa,  separated  from  each  other  by  a 
fibrous  septum.  The  crura  are  covered  by  the  ischio-cavernous  muscles, 
which  serve  the  same  purjjose  as  in  the  male.  It  has  also  a  suspensory 
ligament.  The  corpora  cavernosa  are  composed  of  a  vascular  ])lexus 
with  numerous  traversing  muscular  fibres.  The  arteries  are  derived 
from  the  internal  jnidic  artery,  which  gives  a  branch,  the  cavernous,  to 
each  half  of  the  organ  ;  there  is  also  a  dorsal  artery  distributed  to  the 
prepuce.  According  to  Gusseubauer,  these  cavernous  arteries  pour  their 
blood  directly  into  large  veins,  and  a  finer  venous  plexus  near  the  sur- 
face receives  arterial  blood  from  small  arterial  branches.  By  these 
arrangements  the  erection  of  the  organ  which  takes  place  during  sex- 
ual excitement  is  favored.  The  nervous  supply  6f  the  clitoris  is  large, 
being  derived  from  the  internal  pudic  nerve,  which  supplies  branches  to 
the  corpora  cavernosa,  and  terminates  in  the  glands  and  prepuce,  where 
Paccinian  corpuscles  and  terminal  bulbs  are  to  be  found.  On  this  ac- 
count the  clitoris  has  been  supposed  by  some  to  be  the  chief  seat  of 
voluptuous  sensation  in  the  female. 

The  vestibule  (Fig.  14,  e)  is  a  triangular  space,  bounded    at  its 
apex  by  the  clitoris,  and  on  either  side  by  the  folds  of  the   nymphse. 
It  is  smooth,  and,  unlike  the  rest  of  the  vulva,  is  destitute  of  seljaceous 
glands,  although  there  are  several  groups  of  muci^^ous^^ands  opening 
on~Tfs  surface.     At  the  centre  of    the  base  oi  flie~triaugle,  which  is 
formed  by  the  upper  edge  of  the  opening  of  the  vagina,  is  a  prom- 
inence, distant  about  an  inch  from  the  clitoris,  on  Avhich  is  the  ori- 
fice   of  the  urethra.     This  prominence  can  be  readily  made    out  by 
the  finger,  and  the  depression  upon  it — leading  to  the  urethra — is  of 
importance  as  our  guide  in  passing  the  female  catheter.     This  little 
operation  ought  to  be  performed-  without  exposing  the  patient,  and  it  is    ?j   \^ 
done  in  several  ways.     The  easiest  is  to  place  the  tip  of  the  index'y^  \  ^ 
finger  of  the  left  hand  (the  patient  lying  on  her  back)  on  the  apex  of       /^ 
the  vestibule,  and  slij)  it  gently  down   until  we  feel  the   bulb  of  the     J''^ 
urethra  and  the  dim[)le  of  its  orifice,  which  is  generally  readily  found.p," 
If  there  is  any  diflfieultv  in  finding  the  orifice,  it  is  well  to   remember^ 
that  it  is  placed  immediately  below  the  sharp  edge  of  the  lower  border 
of  the  symphysis  pubis,  which  will  guide  us  to  it.     The   catheter  (and 
a  male  elastic  catheter  is  always  the  best,  especially  during  labor,  when 
the  urethra  is  apt  to  be  stretched)  is  then  passed  under  the  thigh  of  the 
patient,  and  directed  to  the  orifice  of  the   urethra  by  the  finger  of  the 
left  hand,  which  is  placed    upon   it.     AVe   must  be  careful  that  the 
instrument  is  really  passed  into  the  urethra,  and  not  into  the  vagina. 
It  is  advisable  to  have  a  few  feet  of  elastic  tubiuo;  attached  to  the  end 


52  oiiGASs  ('ONcerm:i>  jy  parti  rition. 

of  the  oathotcr,  so  tliat  tlie  uriiu'  can  l)e  j)assc(l  into  a  vessel  inider  the 
bed  without  iiiic()verin<j  the  patient,  i?  the  patient  be  on  her  side  in 
tlie  usual  obstetric  position,  the  opei'ation  can  be  more  readilv  per- 
formed bv  placinjjf  tlie  tip  of  the  tin<;er  in  the  vajrina  and  feeling  its 
upper  cd<re.  The  orilice  of  the  urethra  lies  immediately  above  this, 
and  if  the  catheter  be  sli])i)ed  alon<r  the  ])almar  surface  of  the  finger  it 
can  generally  be  inserted  without  nuieli  trouble.  If,  however,  as  is 
often  the  ease  during  labor,  the  j)arts  are  much  swollen,  it  may  be 
difficult  to  find  the  a[)erture,  and  it  is  then  always  better  to  look  for 
the  oiK'ning  than  to  hurt  the  jiaticnt  i)y  l()ng-c(»utinued  efforts  to  feel  it. 

The  urethra  is  a  canal  l.l  inches  in  length,  and  it  is  intimately  con- 
nected with  the  anterior  wilitnjf  the  vagina,  through  which  it  may  be 
felt.  It  is  composed  of  muscular  and  erectile  tissue,  and  is  remarkable 
for  its  extreme  dilatability — a  |)roj)erty  which  Ts  turned  to  ])ractical 
aecount    in  some  of   the  operations  for  stone  in  the  female    hladder. 

About  an  eighth  of  an  inch  above  its  orifice  are  the  openings  of  two 
glandular  structures  situated  in  its  muscular  walls.  1'hey  are  about 
three-quarters  of  an  inch  in  length,  and  were  fii'st  described  by  Pro- 
fessor Skene  of  Brooklyn.^ 

The  orifice  of  the  vagina  is  situated  immediately  below  the  bulb 
of  the  urethra.  In  virgins  it  is  a  circular  o|x;uing,  but  in  women  who 
have  borne  children  or  practised  sexual  intercourse  it  is,  in  the  undis- 
tended  state,  a  fissure  running  transversely  and  at  right  angles  to  that 
between  the  labia.^  In  virgins  it  is  generally  more  or  less  blocked  up 
by  a  fold_of  mucous  membrane  containing  some  cellular  tissue  and 
muscular  fibres,  Mith  vessels  and  nerves,  which  is  known  as  the  hyhxen. 
This  is  continuous  with  the  anterior  extremity  of  the  vagina,  the 
mucous  membrane  of  which  lines  its  internal  surface,  that  covering  its 
external  surface  being  derived  from  the  mucous  membrane  of  the 
vulva.^  It  is  most  often  crescentic  in  shape,  with  the  concavity  of  the 
crescent  looking  upward  ;  sometimes,  however,  it  is  circular  with  a  cen- 
tral opening  or  cribrifoim  ;  or  it  may  even  be  entirely  iinperforate,  and  this 
gives  I'ise  to  the  retention  of  the  menstrual  secretion.  These  varieties 
of  form  dejiend  on  the  peculiar  mode  of  development  of  the  fold  of 
vaginal  mucous  membrane  which  block?  uj)  the  orifice  of  the  vagina  in 
the  foetus,  and  from  which  the  hymen  is  formed.  The  density  of  the 
membrane  also  varies  in  different  individuals.  INIost  usually  it  is  very 
slight,  so  as  to  be  ruptured  in  the  first  sexual  ajiproaches,  or  even  by 
some  accidental  circumstance,  such  as  stretching  tJie  limbs,  so  that  its 
absence  cannot  be  taken  as  evidence  of  want  of  chastity.  A  know- 
ledge of  this  fact  is  of  considerable  im])f>rtance  from  a  medico-legal 
point  of  view.  Sometimes  it  is  so  tough  as  to  })revent  intercourse  alto- 
gether, and  may  require  division  by  the  knife  or  scissoi*s  before  this 
can  be  effected  ;  and  at  others  it  rather  unfolds  than  ruptures,  so  that  it 
may  exist  even  after  imj)regnation  has  been  effected,  and  it  has  been 
met  with  intact  in  women  who  have  hal)itually  led  unchaste  lives.  In 
a  few  rare  cases  it  has  even  formed  an  ol)stacle  to  delivery,  and  has 
required   incision  during  labor. 

'  Amrr.  Journ.  of  Ohstetrici,  1880,  vol.  xiii.  p.  265.  ■'  Hart.  op.  n't. 

^  Biidin,  Rechercheji  mr  P Hymen  el  rOrijice  vugiiuil,  1879. 


THE  FEMALE  GENERATIVE  ORGANS.  53 

The  carunculse  niyrtiformes  arc  small  fleshy  tubercles,  varying 
from  two  to  Ave  in  number,  situated  round  the  orifice  of  the  vagina, 
and  which  are  generally  sui)|)(»scd  to  be  the  remains  of  the  ruptured 
hvmen.  Schroeder,  however,  maintains  that  they  are  only  formed  after 
childbcaring,  in  conse(|uence  of  })arts  of  the  liymen  having  been 
destroyed  by  the  injuries  received  during  the  passage  of  the  child. 

Vulvo-vaginal  Glands. — Near  the  posterior  })art  of.  the  vaginal 
orifice,  and  below  the  superficial  ])erineal  fascia,  are  situated  two  con- 
glomerate glands  which  are  the  analogues  of  Cowper's  glands  in  the 
male.  Each  of  tliese  is  about  the  size  and  shape  of  an  almond,  and  is 
contained  in  a  cellular  fibrous  envelope.  Internally  they  are  of  a  yel- 
lo\\nsh-white  color,  and  are  composed  of  a  number  of  lobules  separated 
from  each  other  by  prolongations  of  the  external  envelope.  These 
give  origin  to  separate  ducts  which  unite  into  a  common  canal,  about 
half  an  inch  in  length,  which  opens  in  front  of  the  attached  edge  of 
the  hymen  in  virgins,  and  in  married  women  at  the  base  of  one  of  the 
carunculee  niyrtiformes.  According  to  Huguier,  the  size  of  the  glands 
varies  much  in  different  women,  and  they  appear  to  have  some  connec- 
tion with  the  ovary,  as  he  has  always  found  the  largest  gland  to  be  on 
the  same  side  as  the  largest  ovary.  They  secrete  a  glairy,  tenacious 
flj.iid,  which  is  ejected  in  jets  diu'ing  the  sexual  orgasm,  probably 
through  the  spasmodic  action  of  the  perineal  muscles.  At  other  times 
their  secretion  serves  the  purpose  of  lubricating  the  vulva,  and  thus 
preserves  the  sensibility  of  its  mucous  membrane. 

Fossa  Navicularis. — Immediately  behind  the  hymen,  in  the 
unmarried,  and  between  it  and  the  perineum,  is  a  small  depression 
called  the  fossa  navicularis,  which  disappears  after  childbearing. 

The  perineum  separates  the  orifice  of  the  vagina  from  that  of 
the  rectum.  It  is  about  IJ  inches  in  breadth,  and  is  of  great  obstetric 
interest,  not  only  as  supporting  the  internal  organs  from  below,  but 
because  of  its  action  in  labor.  It  is  largely  stretched  and  distended  by 
the  presenting  part  of  the  child,  and,  if  unusually  tough  and  unyield- 
ing, may  retard  delivery,  or  it  may  be  torn  to  a  greater  or  less  extent, 
thus  giving  rise  to  various  stibsequent  troubles. 

Vascular  Supply  of  the  Vulva. — The  structures  described  above 
together  form  the  vulva,  and  they  are  remarkable  for  their  abundant 
vascular  and  nervous  supply.  The  former  iconstitutes  an  erectile  tissue 
similar  to  that  which  has  already  been  described  in  the  clitoris,  and 
which  is  especially  marked  about  the  bulb  of  the  vestibule  (Fig.  15). 
From  this  point,  and  extending  on  either  side  of  the  vagina,  there  is  a 
well-marked  plexus  of  convoluted  veins  which,  in  their  distended 
state,  are  likened  by  Dr.  Arthur  Farre  to  a  filled  leech.  The  erection 
of  the  erectile  tissue,  as  well  as  that  of  the  clitoris,  is  brought  about 
under  excitement,  as  in  the  male,  by  the  compression  of  the  efferent 
veins,  by  the  contraction  of  the  i sch io-cavern o n s  m uscles,  and  by  that 
of  a  thin  layer  of  muscular  tissues  surrounding  the  orifice  of  the  vagina 
and    described  as  the  constrictor  vaginae. 

The  vagina  is  the  canal  which  forms  the  communication  between 
the  external  and  internal  generative  organs,  through  which  the  semen 
passes  to  reach  the  uterus,  the  menses  flow,  and  the  fcetus  is  expelled. 


Ill 


v.^-" 


54 


(jJWASs  foycKRyKi)  IS  rARTrniTioy. 


( 


Kniiiiiily  s|K'akiii<r,  it  lies  in  tlu-  axis  of  tlic  jx-lvis,  l)ut  its  opciiin^'^  is 
placed  aiitn-iur  to  the  axis  ol"  the  jiclvic  outlet,  so  that  its  lower  |tortioii 
is  ciii-vcd  "forward  so  as  to  lie  j)aiallel  to  the  pelvic  brim.  Jt  is  narrow 
beluw,  but  dilateil  above,  where  the  cervix  uteri  is  inserted   into  it,  so 


Fig.  15. 


Vascular  Supply  of  Vulva.    (After  Kobelt.) 

a.  Bulb  of  vestibule.     6.  Muscular  tissue  of   tlie   vagiua.     c,  d,  e,  /.     Tlie   clitoris  and  muscles,    g.  h,  i, 
k,  I,  m,  n.    Veins  of  the  uyniphiu  and  clitoris  communicating  with  the  epigastric  and  obturator  veins. 

that  it  is  more  or  less  conoidal  in  shape.  Under  ordinary  circum- 
stances, especially  in  the  virgin,  fthe  anteri<tr  and  ]K).sterior  walls  lie  in 
close  contact  Avith  each  othei)(see  Plate  1.),  and  there  is,  strictly  s[)eak- 
ins:;,  no  vaginal  canal,  although  they  are  cajiable  of  wide  distension,  as 
in  copulation  and  during  the  i)as.sage  of  the  fwtus.  The  anterior  wall 
of  the  vagina  is  shorter  than  the  posterior,  the  former  measuring  on  an 
/|/ average  2  J  inches,  the  latter  3  inclies  ;  but  the  length  of  the  canal 
varies  greatly  in  different  subjects  and  under  certain  circumstances.  In 
fmjit,  the  vagina  is  closely  connected  with  the  ba.-^e  of  the  bladder,  .m) 
that  when  the  vagina  is  prola[).<ed,  as  often  occurs,  it  drags  the  bladder 
with  it  (Fig.  17);  bchiud,  it  is  in  relation  with  the  rectum,  but  less 
intimately;  laterally,  with  the  broad  ligaments  and  pelvit;  fascia  ;  and 
sui)eriorly,  witn  the  lower  portion  of  the  uterus  and  folds  of  jierito- 
neuin  both  before  and  behind.  The  vagina  is  composed  of  mucous, 
muscular,  and  cellular  coats.  The  mucous  lining  is  thrown  into 
numerous  folds,  'i'hese  stai't  from  longitudinal  ridges  which  exist  on 
both  the  anterior  and  posterior  walls,  but  most  distinctly  on  the  ante- 
rior. They  are  very  numerous  in  the  young  and  unmarried,  and 
greatly  increase  the  sensitive  surface  of  the  vagina  (Fig.  16).  After 
childbearing  and   in  the   aged   they  become  atrophied,  but   they  never 


THE  FEMALE  GENERATIVE  ORGANS. 

Fio.  16. 


55 


Right  Half  of  Virgin  Vagina,  with  walls  held  apart,  showing  the  abundant  transverse  rugse, 
the  greater  depth  of  the  vagina  above  than  below,  and  the  hymeneal  segment.  (After 
Hart.) 

completely  disappear,  and  toward  the  orifice  of  the  vagina,  where  they- 
exist  in  greatest  abundance,  they  are  always  to  be  met  with.  The 
whole  of  the  mucous  membrane  is  lined  with  tessellated  epithelium^ 


Fig.  17. 


Longitudinal  Section  of  Body,  showing  relations  of  generative  organs 


50  ORG  ASS  CONCERNED  IS  I'ARTURITIOX. 

jiiid  it  is  covci-cd  with  a  lartic  imnilM  r  of  jtapilhe,  cillicr  coiii<"al  or 
divided,  wlii<-li  are  liiiihiy  \a>(ular  and  pinjcct  into  the  ei)itiielial 
layer.  Unlii<e  the  vulvar  mueoiis  iiieini>raiie,  that  of"  the  vagiua 
seems  to  be  destitute  oi'  j^and*^-  Beueath  the  e])ithelial  layer  is  a 
sul)n»ucous  tissue  coiitamin^  a  large  iiunibcr  of  elastic  and  some 
imiscular  fibres,  derived  from  the  muscular  walls  of  the  vaf2:ina. 
These  are  stroni^  and  well  developed,  especially  towai-d  the  ostium  vat[i- 
n:e,  where  they  are  arranged  in  a  circular  mass  having  a  si)hinctcr 
action.  They  consist  of  two  layers — an  internal  longitudinal  aiid  an 
external  circular — with  oblique  decussating  fibres  connecting  the  two. 
Below  they  are  attached  to  the  isehio-pubie  rami,  and  above  they  are 
continuous  with  the  muscular  coat  of  the  uterus.  (^The  muscular  tissue^ 
of  the  vagina  increases  in  thickness  during  pregnancy,  but  to  a  much] 
less  degree  than  that  of  the  uterus.)  Its  vascular  an-angements,  like 
those  of  the  vulva,  are  such  as  to  constitute  an  erectile  tissue.  'Jhe 
arteries  form  an  intricate  network  around  the  tube,  and  eventually  end 
in  a  submucous  capillary  plexus  from  which  twigs  pass  to  supply  the 
paj)ilhe  ;  these  again  give  origin  to  venous  radicles  which  unite  into 
meshes  freely  interlacing  with  each  other  and  forming  a  well-marked 
venous  ])lexus. 

2.  The  internal  organs  of  generation  consist  of  the  uterus,  the 
Fallojnau  tubes,  and  the  ovajies;  and  in  connection  with  them  we  have 
to  studv  the  various  ligaments  and  folds  of  ijcritoueum  which  serve  to 
maintain  the  organs  in  position,  along  with  certain  accessory  structures. 
Phvsiologically,  the  most  important  of  all  the  generative  organs  are  the 
ovaries,  in  which  the  ovules  are  formed  and  which  dominate  the  entire 
reproductive  life  of  the  female.  The  Fallopian  tubes,  which  convey  the 
ovule  to  the  uterus,  and  the  uterus  itself — whose  main  function  is  to 
receive,  nourish,  and  eventually  expel  the  impregnated  product  of  the 
ovarv — may  be  said  to  be,  in  fact,  accessory  to  these  viscera.  Practi- 
callv,  however,  as  obstetricians,  we  are  chiefiy  concerned  with  the 
uterus,  and  may  conveniently  commence  with   its  description. 

The  uterus  is  correctly  described  as  a  ])yrU()rm_organ,  flattened  from 
before  backward,  consisting  of  the  body  with  its  rounded  fundus,  an<l 
the  cervix,  which  ])rojects  into  the  upjier  part  of  the  vaginal  canal.  In 
the  adult  female  it  is  deeply  situated  in  the  jxivis,  being  ])laced  between 
the  l)]adder  in  front  and  the  rectum  behindiits  fiindu-  being  below  the 
]»laiir  of  the  |H  Ivic  brim  (Fig.  18)\  Ht  only  assume<  the  position,  how- 
ever, t(j\\ai(l  the  period  of  puberty,  lUid  in  the  fcetns  it  is  placed  nuich 
higher,  and  lies,  indeed,  entirely  within  the  cavity  of  the  abdomenJ  It 
is  maintained  in  this  ]>osition  ]iartly  by  being  slung  by  its  ligantcnts, 
which  we  shall  subscfjuently  study,  and  partly  by  being  suj)ported 
from  beloAV  by  the  pelvic  cellular  tissue  and  the  fleshy  column  of 
the  vagina.  The  result  is  that  the  uterus,  in  the  healthy  female,  is 
a  perfectly  movable  body,  altering  its  ])osition  to  suit  the  condition  of 
the  surrounding  viscera,  especially  the  bladder  and  rectum,  which  are 
subjected  to  variations  of  size  according  to  their  fulness  or  emptiness. 
AVlu'u  from  anv  cause — as,  for  exam]de,  some  ])eriuterine  inflammation 
])rodueing  adhesions  to  the  surrounding  textures — the  mobility  of  the 
organ  is  interfered  with,  much  distress  ensues,  and  if  pregnancy  sui)er- 


THE  FEMALE  (JPJNERATIVE  ORGANS. 


57 


venes  more  or  less  serious  coiisccjiiciicos  may  result.  Generally  speak- 
ing, the  iit(!rus  nuiv  be  said  to  lie  in  a  line  roughly  eorresponding  with 
the  axis  of  the  pelvic  brim,  its  fundus  being  pointed  ibrward,  and  its 
cervix  lying  in  siielTa  direction  thai  a  line  drawn  from  it  would  impinge 


Fig.  18. 


Transverse  Section  of  the  Body,  showing  relations  of  the  fundus  uteri. 
TO.  Pubes.     a  a  (in  front).  Remainder  of  hypogastric  arteries,     a  a  (behind).  Spermatic  vessels  and  nerves. 
B.  Bladder.     L  L.  Round  ligaments.     U,  Fundus  uteri.     I  t.  Fallopian  tubes,    o  o.  Ovaries,    r.  Rec- 
tum,     g.  Right  ureter,  resting  on   the   psoas  muscle,      c.  Utero-sacral  ligaments,     v.  Last  lumbar 
vertebra. 

on  the  junction  between  the  sacrum  and  coccyx.  According  to  some 
authorities,  the  uterus  in  early  life  is  more  curved  in  the  anterior  direc- 
tion, and  is,  in  fact,  normally  in  a  state  of  anteflexion.  Sappey  holds 
that  this  is  not  necessarily  the  case,  but  that  the  amount  of  anterior 
curvature  depends  on  the  emptiness  or  fulness  of  the  bladder,  on  which 


Transvi 


Srctinii  of  rtcrus. 


the  uterus,  as  it  were,  moulds  itself  in  the  iinimpregnated  state.  It  is 
believed  also  that  the  body  of  the  uterus  is  very  generally  twisted  some- 
what obliquely,  so  that  its  interior  surface  looks  a  little  toward  the  right 
side,  this  prol)ably  depending  on  the  presence  and  frequent  distension 


58 


OrxdAyS  CONCERNED  IN  PARTURITION. 


oi'  tliL-  rcvliuu  in  the  left  side  (if  the  pelvis.  '|'lic  anterior  sin-l'ace  of 
the  uterus  is  convex,  antl  is  ei)v<'n'(l^  in  tin-ee-fonrtlis  of  its  extent  by 
the  peritoneum,  which  is  intiinatt'ly  aTInerent  to  it.  Px-low  the  reHec- 
tion  of  the  nienibrane  it  is  lo(»sely  connected  by  celhihir  tissue  to  the 
bhulder,  so  that  any  downward  disphicenient  of  the  uterus  (b'afrs  the 
bladder  alon*:;  with  it.  The  posterior  surface  is  also  convex,  but 
more  distinctly  so  tiian  the  anterior,  as  may  be  observed  in  looking 
at  a  transverse  section  of  tiie  or<>;an  (Fig.  19).  It  is  also  covered  by 
])ei-itoneuin,  tlie  reflection  oi"  which  on  the  rectum  forms  the  cavity 
known  as  Douglas'  pouch.  The  fundus  is  the  upper  extremity  of 
the  uterus,  lying  above  the  j)oints  (Tfentry  of  the  Fallopian  tubes. 
It  is  onlv  slightly  I'ounded  in  tiie  virgin,  but  becomes  more  decid- 
etllv  and  [)ernianently  rounded  in  the  woman  who  has  borne  chil- 
dren. 

Until   the   period  of   pul)erty  the    uterus  remains  small  and   unde- 
veloi)ed  (Fig.  20);  after  that  time  it  reaches  the  adult  size,  at  which 


Fig.  20. 


uterus  and  Appendages  in  an  Infant.    (After  Farrc.) 


it  remains  until  menstruation  ceases,  when  it  again  atro])hies.  If  the 
woman  has  borne  children  it  always  remains  lip-ger  than  in  the  nullii)ara. 
In  the  virgin  adult  the  uterus  measures  2\  inches  from  the  orifice  to  the 
fundus,  ratlier  more  than  half  being  taken  up  by  tlic  cervix.  Its  greatest 
breadth  is  opposite  the  insertion  of  the  Falloi)ian  tubes;  its  greatest 
thickness,  about  11  or  12  lines,  opposite  the  centre  of  its  body.  Its 
average  weight  is  about  9  or  10  drachms.  Indeju'ndently  of  preg- 
nancy, the  uterus  is  subject  to  great  alterations  of  size  toward  the  men- 
strual period,  when,  on  account  of  the  conge.stion  then  present,  it 
enlarges,  sometimes,  it  is  said,  considerably.  This  fact  .should  be 
borne  in  mind,  as  this  periodical  swelling  might  be  taken  for  an 
early  pregnancy. 

For  the  purpose  of  description  the  uterus  is  conveniently  divided  into 

3  X  y^  A   ' 


I  ^, 


g^- 


n  THE  FEMALE  GENERATIVE  ORGANS.  59 

i\\Q  fundus,  with  its  rounded  iij)j)cr  extremity,  sitiuited  between  the  in- 
sertionir()f  the  Fall()i)ian  tubes ;  the  Ixxlji,  which  is  bounded  above  by 
the  insertions  of  the  Fallopian  tubes  auTT  below  by  the  upper  extremity 
of  the  cervix,  and  wiiicli  is  the  part  chiefly  concerned  in  the  rece[)tion 
and  ii^rowth  of  the  ovum;  and  the  cervix,  which  projects  into  the  va^i^ina 
and  dilates  durint;'  labor  to  give  passage  to  the  child.  The  cervix  is 
conical  in  shape,  measuring  11  to  12  lines  transversely  at  the  base,  and 

6  or  7  in  the  antero-posterior  direction  ;  while  at  the  apex  it  measures 

7  to  8  transversely  and  5  antero-posteriorly.  It  projects  about  4  lines 
into  the  canal  of  the  vagina,  the  remainder  of  the  cervix  being  placed 
above  the  reflection  of  the  vaginal  mucous  membrane.  It  varies  nuicli 
in  form  in  the  virgin  and  milliparous  married  Vt'oman  and  in  the  woman 
who  has  borne  children;  and  the  differences  are  of  importance  in  the 
diagnosis  of  pregnancy  and  uterine  disease,  /in  the  virgin  it  is  regu- 
larly pyramidal  in  shape. ")  At  its  lower  extremity  is  the  opening  of  the 
external  os  uteri,  forming  a  sma.ll  circular  opening,  sometimes  difficult  to 
feel,  and  generally  described  as  giving  a  sensation  to  the  examining 
finger  like  the  extremity  of  the  cartilage  at  the  tip  of  the  nose.  It  is 
bounded  by  two  lips,  the  anterior  of  which  is  apparently  larger  on 
account  of  the  position  of  the  uterus.  The  surface  of  the  cervix  and  the 
borders  of  the  os  are  very  smooth  and  regular. 

In  women  who  have  borne  children  these  parts  become  considerably 
altered.  The  cervix  is  no  longer  conical,  but  is  irregular  in  form  and 
shoi-tened.  The  lips  of  the  os  uteri  become  fissured  and  lobulated,  on 
account  of  partial  lacerations  which  have  occurred  during  labor.  The 
OS  is  larger  and  more  irregular  in  outline,  and  is  sometimes  sufficiently 
patulous  to  admit  the  tip  of  the  finger.  In  old  age  the  cervix  atrophies, 
and  after  the  change  of  life  it  not  uncommonly  entirely  disappears,  so 
that  the  orifice  of  the  os  uteri  is  on  a  level  with  the  roof  of  the  vagina. 

The  internal  surface  of  the  uterus  comprises  the  cavities  of  the  body 
'and  cervix — the  former  being  rather  less  than  the  latter  in  length  in. 
virgii^^  but  about  equal  in  women  who  have  borne  children — separated 
from  each  other  by  a  constriction  forming  the  u}i|)cr  boundary  of  the 
cervical  canal.  The  cavity  of  the  body  is  triangular  in  shape,  the  base 
of  the  triangle  being  formed  by  a  line  joining  the  openings  of  the  Fal- 
lopian tubes,  its  apex  by  the  upper  orifice  of  the  cervix,  or  internal  os, 
as  it  is  sometimes  called.  In  the  vjrgin  its  boundaries  are  somewhat 
convex,  projecting  inward.  After  childbearing  they  become  straight  or 
slightly  concave.  The  opposing  surfaces  of  the  cavity  are  always  inl 
contact  in  the  healthy  state,  or  are  only  separated  from  each  other  by  aj 
small  quantity  of  mucous. 

The  cavity  of  the  cervix  is  spindle-shaped  or  fusiform,  narrower 
above  and  below  at  the  internal  and  external  os  uteri,  and  somewhat 
dilated  between  these  two  points.  It  is  flattened  from  before  backward, 
and  its  opposing  surfaces  also  lie  in  contact,  but  not  so  closely  as  those 
of  the  body.  Oii__t]ic  nnicon^  lining  of  the  anterior  and  posterior  sur- 
faces is  a  prominent  ixrpciidicular  ridge,  with  a  lesser  one  at  each  side, 
froiii  which  transverse  ridges  proceed  at  more  or  less  acute  angles.  They 
have  received  the  name  of  the  arbor  vitce.  According  to  Guy  on,  the 
perpendicular  ridges  are  not  exactly  opposite,  so  that  they  fit  into  each 


GO 


OliUAS^  COSiJERSED   IS  rARTUlUTION. 


other,  and  servo  more  completely  to  iill  up  the  cavity  of  the  cervix,  cs- 
l)eeialiy  toward  the  internal  os  (Fio-.  21).  The  arbor  vitte  is  most  dis- 
tinct in  the  virgin,  and  atropliics  considerably  afterV-irrfdbearing-. 


Fig.  21. 


Fig.  22. 


Portion  of  Interior  of  Cervix,  enlarged  nine  diameters.    (.Vfter  Tyler  Smith  and  Ilassall.) 

The  superior  extremity  of  tlie  cervical  canal  forms  a  narrow  isthmus 
separating  it  from  the  cavity  of  the  body,  and  measuring  about  three- 
eighths  of  an  inch  iu  diameter.  Like  the  external  os,  it  contracts  after 
the  cessation  of  menstruation,  and  in  old  age  sometimes  becomes  entirely 
obliterated. 

The  uterus  is  compo.sed  of  three  principal  structures — the  peritoneal, 
mu-scular,  and  mucous  coats.     The  pcritj^ucum  forms  an  investment  to 

the  greater  part  of  the  organ,  extend- 
ing downward  in  front  to  the  level 
of  the  OS  internum,  and  behind  to 
the  top  of  the  vagina,  from  which 
])oints  it  is  reflected  upwai'd  on  the 
bladder  and  rectum  respectively. 
At  tiie  sides  the  peritoneal  invest-/ 
ment  is  not  so  extensive,  for  a  little 
below  the  level  of  the  Fallopian 
tubes  the  peritoneal  folds  sc])arate 
from  each  other,  forming  the  broad 
ligaments  (to  be  afterward  dc^-^cribcd) ; 
here  it  is  that  the  ves.sels  and  nerves 
supplying  the  uterus  gain  access  to  it.  At  the  upper  jxirt  of  the  organ 
the  peritoneum  is  so  closely  adherent  to  the  muscular  tissue  that  it  can- 
not be  separated  from  it ;  below,  the  connection  is  more  loose.     The  mass 


<^ 


Jfuscnlar  Fibres  of  Unimpregnated  Uterus 
(After  Farre.) 

a.  Fihrps  utiitod  hy  ronncctive  tis.sn('. 

6.  Separate  fibres  aiiJ  elementary  corpusclus. 


THE  FEMALE  GENERATIVE  ORGANS. 


61 


of  the  uterine  tissue,  botli  in  the  body  and  cervix,  consists  of  unstriped 
muscular  fibres  (Fig.  22),  firmly  united  toilet  her  by  nucleated  coiuiective 
tissue  and  elastic  fibres.  The  muscular  libre-cellsare  large  and  fusiform 
with  very  attenuated  extremities,  generally  containing  in  their  centi-eadis- 
tinct  nucleus.  These  cells,  as  well  as  their  nuclei,  become  greatly  enlarged 
during  pregnancy  (Fig.  23) :  according  to  Strieker,  this  is  only  the  case 

Fig.  23. 


Developed  Muscular  Fibres  from  the  Gravid  Uterus.    (After  Wagner.) 

with  the  muscular  fibres  which  play  an  important  part  in  the  expulsion 
of  the  foetus,  those  of  the  outermost  and  innermost  layers  not  sharing  in 
the  increase  of  size.^  In  addition  to  these  developed  fibres  there  are, 
especially  near  the  mucous  coat,  a  number  of  roundjelementary  corpus- 
cles,  which  are  believed  by  Dr.  Farre^  to  be  tlie"eTementary  form  of  the 
muscular  fibres,  and  which  he  has  traced  in  various  intermediate  states 
of  development.  i^Dr.  John  Williams^  believes  that  a  great  part  of  the 
muscular  tissue  of  the  uterus — rather  more,  indeed,  than  three-fourths  I 
of  its  thickness — is  an  integral  part  of  the  mucous  membrane,  analogous  (i 
to  the  muscularis  mucosse  of  the  mucous  membrane  of  the  alimentary 
canal.  ]  This  he  describes  as  being  separated  from  the  rest  of  the  muscu- 
lar tissue  by  a  layer  of  rather  loose  connective  tissue  containing  numer- 
ous vessels.  In  early  foetal  life  and  in  the  uteri  of  some  of  the  lower 
animals  this  appearance  is  very  distinct ;  in  the  adult  female  uterus, 
however,  it  cannot  be  readily  made  out. 

On  examining  the  uterine  tissue  in  an  unimpregnated  condition  no 
definite  arrangement  of  its  muscular  fibres  can  be  made  out,  and  the 
whole  seem  blended  in  inextricable  confusion.  By  observation  of 
their  relations  when  hypertrophied  during  pregnancy  Helie*  has  shown 
that  they  may,  speaking  roughly,  be  divided  into  tliree  layers — an  ex- 
ternal ;  a  middle,  chiefly  longitudinal ;  and  an  internal,  chiefly  circular. 
Into  the  details  of  their  distribution,  as  described  by  him,  it  is  needless 
to  enter  at  length.  Briefly,  however,  he  describes  the  external  layer  as 
arising  posteriorly  at  the  junction  of  the  body  and  cervix,  and  spreading 
upward  and  over  the  fundus.  From  this  are  derived  the  muscular 
fibres  found  in  the  broad  and  round  ligaments,  and  more  particularly 
described  by  Rouget.     The  middle  layer,  is  made  up  of  strong  fasciculi^ 

*  Compamti/ve  Histolor/i/,  vol.  iii. ;  Syd.  Soc.  Trans.,  p.  477.  yP"  / 
^   The  Uterus  and  its  Appeudaxjefs,  p.  632.                                                 0 

^  "On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,"  Ohsfei.  Jown., 
1875-76,  vol  iii.  p.  496. 

*  Reeherches  sur  la  Dinposition  dcs  Fibres  mu.'iculaires  de  I'  Uterus,  Paris,  ]  869. 


62 


oi^^■.lxs'  coycEEXED  ly  rAirrriiiTioy 


which  run  uj)\\ar(l,  but  decussate  and  unite  will)  ladi  other  in  a 
remarkable  manner,  so  that  those  whicli  are  at  fii-st  su])ertieial  become 
most  deeply  seated,  and  rice  cer-sd.  The  nmscular  fasciculi  which  form 
this  coat  curve  in  a  circular  manner  round  the  large  veins,  so  as  to  foi-ni 
a  species  of  muscular  canal,  throu<ih  which  they  lun.  This  anan<re- 
ment  is  of  peculiar  importance,  as  it  atibixls  a  satisfactory  explanation 
of  the  mechanism  by  which  hemorrhage  after  delivery  is  ])revented. 
The  internal  layer  is  mainly  composed  of  circidar  rings  of  muscular 
fibres,  begnumig  round  the  openings  of  the  Fallo])ian  tubes,  and  form- 
ing wider  and  wider  circles  which  eventually  touch  and  intcrlacf?  with 
each  other.  They  surround  the  internal  os,  to  which  they  ibrm  a  kind 
of  sphincter.  In  addition  to  these  circular  fibres  on  the  internal  uterine 
surface,  both  anteriorly  and  posteriorly,  there  is  a  well-marked  triangu- 
lar layer  of  longitudinal  fibres,  the  base  being  above  and  the  apex  below, 
which  sends  muscular  fasciculi  into  the  nnicous  membrane. 

The  anatomy  of  the  lining  membrane  of  the  uterus  has  Ijcen  the  sub- 
ject of  considerable  discussion.  Its  existence  has  been  denied  by  many 
authorities,  most  recently  by  Snow  Beck,'  who  maintains  that  it  is  in  no 
sense  a  mucous  membrane,  but  only  a  softened  portion  of  true  uterine 
tissue.  It  is,  however,  pretty  generally  admitted  by  the  best  authoi'ities 
that  it  is  essentially  a  mucous  membrane,  differing  from  others  only  in 
being  more  closely  adherent  to  tlic  subjacent  structuivs,  in  consequence 
of  not  possessing  any  definite  ((mncctive-tissue  frameMork. 

It  is  a  pale  pink  membrane  of  considerable  thickness,  most  marked 
at  the  centre  of  the  body,  where  it  forms  from  one-eighth  to  one-fourth 
of  the  thickness  of  the  whole  uterine  walls.  At  the  internal  os  uteri 
it  terminates  by  a  distinct  border,  which  separates  it  from  the  mucous 
membrane  lining  the  cervical  cavity. 

On  the  surface  of  the  mucous  membrane  may  bo  observed  a  multi- 
tude of  little  openings  about  one-thirtieth  of  a  line  in  width  (^Fig.  24). 


Fig.  24. 


Lining  Membrane  of  Uterus,  hhuwing  niiwuik  of  fMiiillaiitb  and  oriiiccs  ol  uterine  glands. 

( Alter  FarrtM 


From  the  body. 


From  orifice  of  Falloinuti  tube. 


These  are  the  orifices  of  the  utricular  glands,  which  are  found  in  im- 
mense numbers  all  over  the  cavity  of  the  uterus,  and  very  closely 
agglomerated  together.  They  are  little  cul-de-sacs,  narrower  at  their 
mouths  than  in  their  length,  the  blind  extremities  of  which  are  found 
in  the  subjacent  tissues  (Fig.  26).  A\'illiams  describes  them  as  running 
obliquely  toward  the  siu-face  at  the  lower  third  of  the  cavity,  perjicn- 
dicularly  at  its  middle,  while  toward  the  fundus  they  are  at  first  per- 

1  Obst.  Trans.,  1872,  vol.  xiii.  p.  294. 


THE  FEMALE  GENERATIVE   ORGANS. 


63 


Fig.  25. 


pendicular,  and  then  oblique  in  their  course  (Fig.  25).  By  others  they 
are  described  as  being  often  twisted  and  corkscrew-like.  One  or  more 
may  unite  to  form  a  common  orifice,  several 
of  which  may  open  together  in  little  pits  or 
depressions  on  the  surface  of  tiie  nmcous  mem- 
brane. These  glands  arc  composed  of  struc- 
tureless membrane  lined  with  epithelium,  the 
precise  character  of  which  is  doubtful.  By 
some  it  is  described  as  columnar,  by  others 
tessellated,  and  l)y  some,  again,  as  ciliated. 
The  most  generally  received  opinion  is  that  it 
is  columnar,  butjiiot  ciliated;  therein  differing 
froiiTThe  epithelium  covering  the  surface  of 
the  membrane,  which  is  undoubtedly  ciliated, 
the  movements  of  the  cilia  being  from  wTtKin 
outward.  Williams,  however,  has  observed 
cilia  in  active  movement  on  the  columnar  epi- 
thelium lining  the  glands,  and  also  states  that 
at  the  deep-seated  extremities  of  the  glands, 
which  penetrate  between  the  muscular  fibres 
for  some  distance,  the  columnar  epithelium  is 
replaced  by  rounded  cells.  The  capillaries  of 
the  mucous  membrane  run  down  between  the 
tubes,  forming  a  lacework  on  their  surfaces 
and  round  their  orifices.  No  true  papillae 
exist  in  the  membrane  lining  the  uterine 
cavity.  The  mucous  membrane  of  the  uterus 
is  peculiar  in  being  always  in  a  state  of  change 
and  alteration,  being  thrown  off  at  each  men-  The  Course  of  the'^Giands  in  the 
strual  period  in  the  form_  of  debris  in  conse-  Stflh?  uterus-viz'%"i 
quence  of  fatty  degeneration  of  its  structures,      bef9re  the  onset  of  a  menstrual 

^    T  f,  i      n®'  i-T  !.<>       ,.  r.   ,1  period.    (After  Williams.) 

and  re-iormed  afresh  by  proliferation  of  the 

cells  of  the  muscular  and  connective  tissues,  probably  from  below  upward, 
the  new  membrane  commencing  at  the  internal  os.  Hence  its  appear- 
ance and  structure  vary  considerably  according  to  the  time  at  which  it 
is  examined.  The  subject,  however,  will  be  more  particularly  studied 
in  connection  with  menstruation. 

The  mucous  membrane  of  the  cervix  is  much  thicker  and  more  trans- 
parent than  that  of  the  body  of  the  uterus,  from  which  it  also  differs  in 
certain  structural  peculiarities.  The  general  arrangements  of  its  folds 
and  surface  have  already  been  described.  The  lower  half  of  the  mem- 
brane lining  the  cavity  of  tlie  cervix,  and  the  whole  of  that  covering 
its  external  or  vaginal  portion,  are  closely  set  with  a  large  number  of 
minute  filiform  or  clavate  pajiillse  (Fig.  27).  Their  structure  is  similar 
to  that  oT  the  mucous  membrane  itself,  of  which  they  seem  to  be  merely 
elevations.  They  each  contain  a  vascular  loop  (Fig.  28),  and  they  are 
believed  by  Kilian  and  Farre  to  be  mainly  concerned  in  giving  sensi- 
bility to  this  part  of  the  generative  tract.  All  over  the  interior  of  the 
cervix,  both  on  the  ridges  of  the  mucous  membrane  and  between  their 
folds,   are  a   very  large   number  of   mucous    follicles  consisting  of  a 


64 


ORGAXS  COSCKliSi:!)    IS   PAim' I'JTIOS. 


stnictiirt'lcss  hu'IuIjimhc  lined  with  cyljiHlrical  cpitlicliiim  and  inti- 
inati'ly  united  with  coniu'ctive  tissue.  Tliey  ceji^e  at  tlie  external 
oriHeo  of"  tlie  cervix,  and  tliey  secrete  the  thiek,  tenacious,  and  alka- 
line mucus  which  is  generally  lound  filling  the  ccrvitid  cavity. 
The  trans[)arent  follicles,  known  as  the  '^  ocu(<i  Jutbothii"  which  are/ 
sometimes  found  in  eonsiderahle  nund)ers  in  tlie  cavity  of  the  cervixi 
consist  of  mucous  follicles  the  mouths  of  which  have  become  oltstructecl 
and  their  canals  distended  by  mucous  secretion.  i^The  lower  third  tif  thti 
cervical  canal,  as  well  as  the  exterior  of  the  cervix,  is  covered  with 
payenient  epithelium  ;  while  on  its  ujipor  portion  is  found  a  colum- 
nar and  ciliated  epithelium  similar  to  that  lining  the  uterine  cavity.^ 


Fig.  26. 


s^ES^a^?!    , 


Vertical  Section  through  the  Mucous  Membrane  of  the  Human  Uterus,    (.\fter  Turner.) 

e.  ColuniDar  epithelium;  the  cilia  .ire  not  rt'prescnteil.     g  g.  Utriciiliir  glands,    cl  ct.  Interglandiilar  con- 
nective tissue.     V  V.  Blood-vessels,    m  m.  Muscularis  mucosw  (*}"). 

Bandl '  describes  the  cervical  mucous  membrane  as  extending  much 
higher  in  the  virgin  than  in  women  Avho  have  borne  children,  being 
traceable  in  the  former  nearly  to  the  middle  of  the  body  of  the  uterus. 
During  the  first  jn-egnancy  he  believes  that  the  ui)per  portion  of  the 
cervix  is  taken  up  into  the  body  of  the  uterus,  its  mucous  membrane 
never  regaining  the  arrangement  ])e('iiliar  to  that  of  the  cervical 
canal. 

The  arteries  of  the  uterus  are  derived  from  the  internal  iliac  and 
from  the  ovarian.  They  enter  the  uterus  between  the  folds  of  the 
broad  ligaments,  and,  jienctrating  its  mu.scular  coat,  anastomo.se  freely 
M'ith  each  other  and  w'ith  the  corresjionding  vessels    of   the  opposite 

^Arch.f.  Oyndk.,  1879,  Bd.  xiv.  S.  237. 


THE  FEMALE  GENERATIVE  ORGANS. 

Fig.  27. 


65 


Villi  of  Os  Uteri  stripped  of  Epithelium.    (After  Tyler  Smith  and  Hassall.) 

side.  They  are  described  by  Williams  ^  as  entering  the  uterus  on  its 
sides,  and  then  running  a  somewhat  superficial  course,  being  separated 
from  the  peritoneum  by  a  thin   layer  of  muscular  fibres.     They  are 

Fig.  28. 


Villi  of  Uterus,  covered  with  pavement  epithelium  and  containing  looped  vessels.    (After  Tyler 

Smith  and  Hassall.) 

-  Tram.  Obst.  Societij,  1885,  vol.  xxvii.  p.  112. 


66  ORGANS  COyCERSEh   L\  PAIiTURrTIOX. 

licre  placed  in  a  distinct  layer  ol'  eonnoctive  ti.ssne,  and  give  oiY 
branches  which  pass  perjjendicularly  toward  the  uterine  canal.  Their 
ualls  are  thick  and  ucll  developed,  and  they  are  renuirkahle  for  their 
very  tortuous  coui'se,  iorniiii'^  spii'al  curves,  especially  in  the  upper  part 
of  the  uterus.  They  end  ni  niiiuite  capillarii's  which  form  the  tine 
meshes  surrounding  the  glands,  and  in  the  cervix  give  oti"  the  loops 
entering  tlie  papillae.  Beneath  the  uterine  nuicous  membrane  these 
capillaries  form  a  plexus  terminating  in  veins  without  valves,  which 
unite  with  each  other  to  form  the  large  veins  traversing  the  substance 
of  the  uterus,  known  (hu'ing  pregnancy  as  the  uterine  sinuses,  the  walls 
of  which  are  closely  adherent  to  the  uterine  tissues.  These  veins  run 
a  similar  course  to  the  arteries,  and  end  in  a  venous  ])lexus  lying  in  the 
layer  of  connective  tissue  already  mentioned,  which  Williams  believes 
to  be  the  true  submucous  tissue  of  the  uterus,  the  thick  layer  of  mus- 
cular tissue  between  it  and  the  uterine  cavity  being  really  "  nniscularis 
mucosre."  lu  consequence  of  this  arrangement  the  circulation  of  the 
uterus  can  hardly  be  disturbed  by  mechanical  causes.  The  veins,  freely 
anastomosing  with  each  other,  pass  from  the  uterus  to  the  folds  of  the 
broad  ligaments,  where  they  unite  to  form,  with  the  ovarian  and  vagi- 
nal veins,  a  large  and  well-developed  venous  network  known  as  the 
jxt mpinifovm  i)lexu><. 

The  Ivmjjhatics  of  the  uterus  arc  large  and  well  developed,  and  they 
have  recently,  and  with  much  probability,  been  supposed  to  ])lay  an 
important  part  in  the  production  of  certain  puerperal  diseases.  A 
more  minute  knowledge  than  Ave  at  present  possess  of  their  course  and 
distribution  will  probably  throw  nuich  light  on  their  influence  in  this 
respect.  According  to  the  researches  of  Leopold,'  who  has  studied 
their  minute  anatomy  carefully,  they  oi-iginate  in  lymph-S])aces  l)etween 
the  fine  l)undles  of  connective  tissue  forming  the  basis  of  the  mucous 
lining  of  the  uterus.  Here  they  are  in  intimate  contact  with  the  utric- 
ular glands  and  the  ultimate  ramifications  of  the  uterine  blood-vessels. 
As  they  pass  into  the  muscular  tissue  they  become  gradually  narrowed 
into  lymph-vessels  and  spaces,  which  have  a  very  com})licated  arrange- 
ment, and  which  eventually  unite  together  in  the  external  nuiscular 
layer,  especially  on  the  sides  of  the  uterus,  to  form  large  canals  Mhich 
probably  have  valves.  Immediately  under  this  i)eritoneal  covering 
these  lymph-vessels  form  a  large  and  characteristic  network  covering 
the  anterior  and  posterior  surfaces  of  the  uterus,  and  present,  in  various 
parts  of  their  course,  large  ampulla?.  They  then  spread  over  the  Fal- 
lopian tubes.  The  lymphatics  of  the  body  of  the  ut(n'us  unite  with 
the  luml)ar  glands,  those  of  the  cervix  with  the  jielvic  glands. 

The  distribution  and  arrangement  of  tlie  iieryes  of  the  uterus  have 
been  the  subject  of  much  controversy.  They  are  derived  mainly  from 
the  ovarian  and  hypiogastric  plexuses,  inosculating  freely  Mith  each 
other  between  the  folds  of  the  broad  ligament,  from  whicli  they  enter 
the  nuiscular  tissue  of  the  uterus,  o;cnerally,  but  not  invariably,  follow- 
ing the  course  of  the  arteries.  (They  are  chiefly  derived  from  the 
sympathetic]  but  as  the  hy})ogastric  plexus  is  connected  with  the  sacral 
iiervesJ  it  is  probable  that  some  fibres  from  the  cerebro-spinal  system  are 
'  Arch.  J.  GyndL,  1873,  Bd.  vi.  Heft  1,  S.  1. 


THE  FEMALE  GENERATIVE  ORGANS.  67 

distributed  to  the  cervix.  Jt  i.s  now  generally  admitted  that  nervous 
filaments  are  distributed  to  the  cervix  even  as  far  as  the  external  os, 
although  their  existence  in  this  situation  has  been  denied  by  Jobert  and 
other  writers.  The  ultimate  distribution  of"  the  nerves  is  not  yet  made 
out.  Polle  describes  a  nerve-filament  as  entering  the  papilhe  of"  the 
cervical  mucous  membrane  along  with  the  capillary  looj),  and  Franken- 
hauser  says  the  nerve-fibres  surround  the  muscles  of"  the  uterus  in  the 
form  of  plexuses  and  terminate  in  the  nuclei  of  the  muscle-cells. 

Anomalies  of  the  Uterus. — Various  abnormal  conditions  of  the 
uterus  and  vagina  are  occasionally  met  with  which  it  is  necessary  to 
mention,  as  they  may  have  an  important  practical  bearing  on  parturi- 
tion. The  most  frequent  of  these  is  the  existence  of  a  double,  or  par- 
tiallv  double,  uterus  (Fig.  29),  similar  to  that  fouud  normally  in  many 

Fig.  29. 


Bifid  Uterus.    (After  Farre.) 

of  the  lower  animals.  This  abnormality  is  explained  by  the  develop- 
ment of  the  organ  during  foetal  life.  The  uterus  is  formed  out  of 
structures  existing  only  iu  early  foetal  life,  known  as  the  ^Yolfiian 
bodies.  These  consist  of  a  number  of  tubes  situated  on  either  side  of 
the  vertebral  column  and  opening  externally  into  an  excretory  duct. 
Along  their  external  border  a  hollow  canal  is  formed,  termed  the  canal 
of  Miiller,  which,  like  the  excretory  ducts,  proceeds  to  the  common 
oloaca  of  the  digestive  and  urinary  organs  which  then  exists.  CThe, 
canal  of  Miiller  unites  with  its  fellow  of  the  opposite  side  to  form  the- 
uterus  and  Fallopian  tubes  in  the  female,  and  subsequently  the  central 
partition  at  their  point  of  junction  disappears.  ^  If,  however,  the  prog- 
ress of  development  be  in  any  way  checked,  the  central  partition  may 
remain.  Then  we  have  produced  either  a  complete  double  uterus  or 
the  uterus  bicoruis,  which  is  bifid  at  its  upper  extremity  only  ;  or  a 
double  vagina,  each  leading  to  a  separate  uterus. 

If  pregnancy  occur  in  any  of  these  anomalous  uteri — and  many 
such  cases  are  recorded — serious  troubles  may  follow.  It  may  ha]^pen 
that  one  horn  of  the  double  uterus  is  not  sufficiently  large  to  admit  of 
pregnancy  going  on  to  term,  and  rupture  may  occur.  It  is  supposed 
that  some  cases,  presumed  to  be  tubal  gestation,  were  really  thus  expli- 
cable.    Impregnation  may  also  occur  in  the  two  cornua  at  diftereut 


G8  ORG  Ays  CONCERXEJJ  jy  PMlTmiTION. 

tinio.<,  leading  to  .supcrluitatuMi.  It  is,  however,  quite  jjossible  that 
iini)re5j:;nation  may  oeeiir  m~one  horn  of  a  bifid  uterus,  and  labor  be 
conij)leted  without  anytliing  unusual  being  observed.  A  remarkable 
case  of  this  sort  has  been  recorded  by  iJr.  Koss  of  JJrighton,'  in  which 
a  i)atient  miscarried  of  twins  on  July  IG,  1870,  and  on  October  31, 
filteen  weeks  later,  she  was  tlelivered  of  a  healthy  child.  C'areiul 
examination  showed  the  existence  of  a  complete  double  uterus,  each 
side  of  which  had  been  impregnated.  Curiously  enough,  this  patient 
had  formerly  given  birth  to  six  living  children  at  term,  nothing 
remarkable  having  been  observed  in  her  labors.  It  can  only  rarely 
hapi)en  that,  under  such  circumstances,  so  favorable  a  result  Mill 
follow,  and  more  or  less  difficulty  and  danger  may  generally  be 
expected.  Occasionally  the  vagina  only  is  double,  the  uterus  being 
single.  Dr.  Matthews  Duncan  has  recorded  some  eases  of  this  kind,^ 
in  which  the  vaginal  se})tum  formed  an  obstacle  to  the  birth  of  the 
child,  and  required  division. 

Fig.  30. 


Uterus  Septus  Tniforis.    (From  Kussmaul,  after  Gravel.) 
«.  Vagina.      6.  Sinple  os  uteri,    c.  Partition  of  ..torus,  tl.ick  ..Ik.vc-  ai.d   thir.  Ixlow.      d  d.  Eight  and  Icit 
^  merine  cavities,     e  e.  Two  ridges  i..  the  posterior  wall  of  the  ce.MX. 

[Double  uteri  are  of  several  di.stinct  types,  the  extremes  of  which  are 
the  " p.\rtitione(J  uterus,"  where  the  organ  is  single  without  and  double 
within,  and  the  ^^" "completely  bifi(l_jiterus,^'  where  there  is  a  dmible  va- 
gina and  cervix  with  a  Y-shaped  or  double-barrelled  body.  The  for- 
mer can  onlv  be  diagno.sticated  from  within,  and  is  rarely  discovered 
until  after  the  second  sta^e  of  a  labor  has  Ijccn  completed.  In  a  ca.se 
reported  by  Dr.  B.  F.  IWr  of  Philadelphia  the  ]>atient  bore  twins,  one 
fcEtus  from'  each  compartment,  the  birth  of  which  was  followed  by  two 

•  Lancet,  1S71,  vol.  ii.  p.  188.  '  Researches  in  ObsUtrk.^  i».  443. 


THE  FEMALE  GENERATIVE  ORGANS.  69 

single  phicentje  at  intervals  of  a  quarter  of  an  hour.  Where  there  is 
only  one  foetus  the  uterus  develops  mainly  on  one  side,  and  the  unoccu- 
pied one  lies  much  lower  than  the  fundus  of  the  other.  Dr.  Drysdale  of 
this  city  discovered  one  such  case  by  the  touch  after  labor,  and  no  doubt 
a  (direful  scrutiny  would  find  that  they  are  less  rare  than  might  be 
presumed. 

Pregnancy  in  a  uterus  nnicornus  is  apt  to  terminate  fatally  by  rup- 
ture, but  exceptional  cases  may  occur  and  the  foetus  be  delivered  at  term. 
In  one  ca.se  seen  by  the  writer  the  development  of  the  abnormal  uterus 
gave  rise  to  much  pain  and  distress  for  several  months,  and  an  extra- 
uterine pregnancy  was  regarded  as  almost  certain  by  the  family  physi- 
cian. The  child  Avas  a  female  of  four  pounds,  and  died  in  three  days 
from  an  undeveloped  duodenum  and  an  imperforate  rectum:  the  coruu 
was  on  the  right  side. — Ed.] 

Lig-aments  of  the  Uterus. — The  various  folds  of  peritoneum  which 

invest  the  uterus  serve  to  maintain  it  in  position,  and  they  are  described 

^  as  its  ligaments.     They  are  the  broad,  the  vesico-uterine,  and  sacro- 

^terine  ligaments ;  theToimd  [igiiments  are  not  peritoneal  folds  like  the 

others. 

The  broad.  Hgaments  extend  from  either  side  of  the  uterus,  where 
their  lamiute  are  separated  from  each  other,  transversely  across  to  the 
pelvic  wall,  and  thus  divide  the  cavity  of  the  pelvis  into  two  parts,  the 
anterior  containing  the  bladder,  the  posterior  the  rectum.  Their  upper 
borders  are  divided  into  three  subsidiary  folds,  the  anterior  of  which 
contains  the  round  ligament,  the  middle  the  Fallopian  tube,  and  the 
posterior  the  ovary.  The  arrangement  has  received  the  name  of  the 
aJa  vespertilionis,  from  its  fancied  resemblance  to  a  bat's  wing.  Between 
the  folds  of  the  broad  ligaments  are  found  the  uterine  vessels  and  nerves, 
and  a  certain  amount  of  loose  cellular  tissue  continuous  with  the  pelvic 

Fig.  31. 


/ 
Adult  Parovarium,  Ovary,  and  Fallopian  Tube.    (After  Kobelt.) 

fiiscifB.  Here  is  situated  that  peculiar  structure  called  the  organ  of 
E,osenmuller,  or  the  parovarinni  (Fig.  31),  which  is  the  remains  of  the 
Wolffian  body  and  corresponds  to  the  epididymis  in  the  male.     This 


70 


ORGASS  COyCERyEl)   IS  PARTURITION. 


may  best  be  seen  in  yonnf;;  snbjccts  by  lioldin^'-  up  llic  Itroad  li^nients 
and  Ittokinij;  tlin»n<ili  tlicni  by  transmitted  bi:lii  ;  Imi  it  exists  at  all 
aji'es.  It  e()nsists  itl"  several  tnbes  (ei^lit  or  ten  aee<ti'(lintr  t<i  Fai'i'e, 
eiirbteen  or  twenty  aeconlinji.-  to  JJankes'),  wliieli  aiv  tortnons  in  their 
eoui-se.  riiey  are  arranucd  in  a  pyraniitlal  lorni,  the  base  of"  the  pyra- 
mid being  toward  the  Fallopian  tube,  its  apex  being  lost  on  the  surliu-e 
ot"  the  ovary.  They  are  formed  of  Hbrous  tissue  and  lined  with  pave- 
ment ej)ithelium.  (  They  have  no  exeretory  duet  or  eonununieation  with 
*  either  the  uterus  or  ovary,  and  their  function,  if  they  have  any,  is 
unknown. 

A  nund)er  of  muscular  tii^res  are  also  ibuiid  in  this  situation,  lying 
between  the  meshes  of  the  connective  tissue.  They  have  been  j)articu- 
larly  studied  by  Kouget,  who  describes  them  as  interlacing  with  each 
other,  and  forming  an  oj)en  network  continuous  with  the  nniscular  tis- 
sues of  the  uterus  (Fig.  32).     They  are  divisible  into  two  layers,  the 

Fig.  32. 


mM 


'■\  \J^ 


\ 


W4 


Posterior  View  of  Mnsfiilar  mill  \axiilar  Arrangements,    (.\fter  Roupet.) 
Fewe^i:  1,  2,  3.  Vntrinal,  cfn-ic.il,  ami  uterine  pli'xusrs.    4.  ,\rtiTics  (irinulydt'iitiTiiH.    5.  .Xrterios  supply- 
infr  ovary.     Muscular  FuKiculi :  G,  7.     Filircs  altiulicil  to  vagiim,  symphysis  imliis.  aii<l  Nicro-iliao  joint. 
8.  Jtiisriilar  fusciculi  from  uterus  and  broad  liganionts.    H,  10,  11,  12.     Fiibciculi  attaoht'd  to  ovary  and 
Fallopian  tnbes. 


anterior  of  which  is  continuous  Mith  the  nniscular  fil)res  of  the  anterior 
surface  of  the  uterus,  and  goes  to  form  ]iart  of  the  round  ligament  ;  the 
posterior  arises  from  the  posterior  wall   of  the   uterus,  and  })roceeds 

'  Bankes,  On  (he  Wolffian  Bodies. 


THE  FEMALE  GENERATIVE  ORGANS.  71 

transversely  outward,  to  become  attached  to  the  sacro-iliac  synchondrosis. 
A  continuous  nuiscuhir  envelope  is  thus  formed  which  surrounds  the 
(whole  of  the  uterus,  Fallopian  tubes,  and  ovaries.  Its  function  is  not 
yet  thoroughly  established.  It  is  supposed  to  have  the  effect  of  retract- 
ing the  stretched  folds  of  peritoneum  after  delivery,  and  more  especially 
of  bringing  the  entire  generative  organs  into  harmonious  action  during 
menstruation  and  the  sexual  orgasm ;  in  this  way  exj^Iaining,  as  we 
shall  subsequently  see,  the  mechanism  by  which  the  fimbriated  extrem- 
ity of  the  Fallopian  tube  grasps  the  ovary  prior  to  the  rupture  of  a 
Graafian  follicle. 

The  round  lig-aments  are  essentially  muscular  in  structure.  They 
extend  from  the  ujiper  border  of  the  uterus,  with  the  fibres  of  which 
their  muscular  fibres  are  continuous,  transversely,  and  then  obliquely 
dt)wnward,  until  they  reach  the  inguinal  rings,  where  they  blend  with. 
the  cellular  tissue.  In  the  first  part  of  their  course  the  muscular  fibres 
are  solely  of  the  unstriped  variety,  but  soon  they  receive  striped  fibres 
from  the  transversalis  muscles  and  the  columns  of  the  ing-uinal  rins:, 
which  surround  and  cover  the  unstriped  muscular  tissue.  In  addition 
to  these  structures  they  contain  elastic  and  connective  tissue  and  arterial, 
venous,  and  nervous  branches ;  the  former  from  the  iliac  or  cremasteric 
arteries,  the  latter  from  the  genito-crural  nerve.  According  to  Mr.j 
Rainey,  the  principal  function  of  these  ligaments  is  to  draw  the  uterusj 
toward  the  symphysis  pubis  during  sexual  intercourse,  and  thus  to  favor) 
the  ascent  of  the  semen. 

The  vesico -uterine  lig-aments  are  two  folds  of  peritoneum  passing 
in  front  from  the  lower  part  of  the  body  of  the  uterus  to  the  fundus  of 
the  bladder. 

The  utero-sacral  lig-aments  consist  of  folds  of  peritoneum  of  a 
crescentic  form,  with  their  concavities  looking  inward  ;  they  start  from 
the  lower  part  of  the^  posterior  surfiice  of  the  uterus,  and  curve  backward 
to  be  attached  to  the  third  and  fourth  sacral  vertebrae.  Within  their 
folds  exist  bundles  of  muscular  fibres  continuous  with  those  of  the 
uterus,  as  well  as  connective  tissue,  vessels,  and  nerves.  (The  experi- 
ments of  Savage,  as  well  as  of  other  anatomists,  show  that  these 
ligaments  have  an  important  influence  in  preventing  downward  dis- 
placement of  the  womb.) 

During  pregnancy  all  these  ligaments  become  greatly  stretched  and 
unfolded,  rising  out  of  the  pelvic  cavity  and  accommodating  themselves 
to  the  increased  size  of  the  gravid  uterus  ;  and  they  again  contract  to 
their  natural  size,  possibly  through  the  agency  of  the  muscular  fibres 
contained  within  them,  after  delivery  has  taken  place. 

The  Fallopian  tubes,  the  honmln^ucs  of  the  vasa  dcllTentia  in  the 
male,  are  structures  of  great  physiological  interest.  They  serve  the 
double  purpose  of  conveying  the  semen  to  the  ovary  and  of  carrying  the 
ovule  to  the  uterus.  From  the  latter  function  they  may  be  looked  on 
as  the  excretory  ducts  of  the  ovaries ;  but,  unlike  other  excretory  ducts, 
they  are  ino^^ible,  so  that  they  may  apply  themselves  to  the  part  of  the 
ovaries  from  which  the  ovule  is  to  come ;  and  so  great  is  their  mobility 
that  there  is  reason  to  believe  that  a  Fallopian  tul)e  may  even  grasji  the 
ovary  of  the  opposite  side.     Each  tube  proceeds  from  the  upper  angle 


72 


ORGANS  CONCERNED  IN  J>AJiTriiITlON. 


of  the  uterus  at  fii-st  transversely  outward,  and  tlien  downward,  back- 
ward, and  inward,  so  as  to  rcacli  the  nei<:;hh(»i  IkhkI  ol"  the  ovary.  In  tne 
first  ])art  of"  its  coui'se  it  is  straight  ;  aftei-ward  it  Ix-conics  fiexuous  and 
twisted  on  itself.  It  is  contained  in  the  nj)iH'r  part  of  tTIe^  hroad 
liu-anicnt,  wiiere  it  may  be  felt  as  a  hard  cord.  It  commences  at  the 
uterus  by  a  narrow  opening,  admitting  only  the  jKtssage  of  a  bristle, 
known  as  ostiinn  nierinum.  As  it  pitsses  through  the  muscular  walls  of 
the  uterus  the  tube  takes  a  somewhat  cin-ved  course,  and  f)j)ens  into  the 
uterine  cavity  by  a  dilated  aj)erture.  From  its  uterine  attachment  the 
tube  expands  gradually  until  it  terminates  in  its  trumjx-t-shaped  ex- 
tremity;  just  l)efore  its  distal  end,  however,  it  again  contracts  slightly. 
The  ovarian  end  of  the  tube  is  surrounded  by  a  number  of  remarkable 
fringe-like  processes.  These  consist  of  longitudinal  mend)ranous  fim- 
bria?, surrounding  the  aperture  of  the  tube  like  the  tentacles  of  a  lH»lyp, 
varying  considerably  in  number  and  size  and  luiving  their  edges  cut 
and  sul)divided.  On  their  iinier  surface  are  found  both  transverse  and 
lon.gitiitHnaL folds  of  mucous  iiieml)rane  continuous  with  those  lining 
the  tube  itself  (Fig.  33).     One  of  these  fimbriie  is  always  larger  and 

Fig.  33. 


Fallopian  Tube  laid  open.    (After  Richard.) 

a,  h.  Uterine  portion  of  tube,    c,  d.  Plica?  of  mucous  inenibrane.    e.  Tubo-ovarian  ligaments  and  fringes. 

/.  Ovary,     g.  Round  ligaments. 

more  developed  than  the  rest,  and  is  indirectly  united  to  the  surface  of 
the  ovary  by  a  fold  of  peritoneum  proceeding  from  its  external  surface. 
Its  under  surface  is  grooved  so  as  to  form  a  channel,  open  below.  The 
function  of  this  fringe-like  .structure  is  to  grasp  the  ovary  during  the 
menstrual  nisus ;  and  the  fimbria  which  is  attached  to  the  ovary  would 
seem  to  guide  the  tentacles  to  the  ovary  which  they  are  intended  to 
seize.  One  or  more  supplementary  .series  of  Hmbri;e  sometimes  exi.>^t, 
which  have  an  a])erture  of  communication  with  the  canal  of  the  Fallo- 
pian tube,  beyond  its  ovarian  extremity.  His  has  recently  shown  that 
the  fimbriated  extremity  of  the  tube,  after  running  over  the  upjier  part 
of  the  ovary,  turns  down  along  its  free  border,  .so  that  its  aperture  lies 


THE  FEMALE  GENERATIVE  ORGANS.  73 

below  it,  ready  to  receive  the  ovule  when  ex])elled  from  the  Graafian 
follicle/ 

The  tubes  themselves  consist  of  peritoneal,  muscular,  and  raucous 
coats.  The  peritoneum  surrounds  the  tube  for  three-fourths  of  its  cal- 
ibre, and  comes  into  contact  with  the  mucous  lining;  at  its  fimbriated 
extremity,  the  only  instance  in  the  body  where  such  junction  occurs. 
The  muscular  jcoat  is  principally  com])osed  of  cjrcu]ar_fi])i-es,  with  a 
few  longitudinal  fibres  interspersed.  Its  nmscular  character  has  been 
doubted,  but  Farre  had  no  difficulty  in  demonstrating  the  existence  of 
muscular  fibres  both  in  the  human  female  and  many  of  the  lower  ani- 
mals. According  to  Robin,  the  muscular  tissue  of  the  Fallopian  tubes  i 
is  entirely  distinct  from  that  of  the  uterus,  from  which  he  describes  it 
as  being  separated  by  a  distinct  cellular  septum.  The  mucous  lining  is 
thrown  into  a  number  of  reinarkable  longitudinal  folds,  each  of  which 
contains  a  dense  and  vascular  fibrous  septum  wdth  small  muscular 
fibres,  and  is  covered  with  columnar  and  ciliated  epithelium.  The 
apposition  of  these  produces  a  series  of  minute  capillary  tubes,  along 
which  the  ovules  are  propelled,  the  action  of  the  cilia,  which  is  toward 
the  uterus,  apparently  favoring  their  progress. 

The  ovaries  are  the   bodies  in  which  the  ovules  are  formed  and 
from  which  they  are  expelled,  and  the  changes  going  on  in  them,  in 
connection   with  the  process  of   ovulation,    during  the  whole   period 
between  the  establishment  of  puberty  and   the  cessation   of  menstru- 
ation, have  an  enormous  influence  on  the  female  economy.     Normally,  \ 
the  ovaries  are  two  in  number ; (in  some  exceptional  cases  a  supplemen-  1 
tary  ovary  has  been  discovered,Yor  they  may  be  entirely  absent. )  They  \ 
are  ])laced  in  the  posterior  folds  of  the  broad  ligaments,  usually  below  I 
the  brim  of  the  pelvis,  behind  the  Fallopian  tubes,  'the  left  in  front  of. 
the  rectum,  fthe  right  in  front  of  some  coils  of  the   small  intestine.'  J 
Their  situation  varies,   however,   very  much  under  different  circum- 
stances, so  that  they  can  scarcely  be  said  to  have  a  fixed  and  normal 
position ;  most  probably,  however,  as  has  been  recently  shown  by  His,^ » 
Cthey  are  normally  placed  close  below  the  brim  of  the  pelvis,  with  their 
long  diameters  almost  vertical,  and  immediately  above  the  aperture  ofl 
the  distal  extremity  of  the  Fallopian  tubes.^   In  pregnancy  they  ris^ 
into  the  abdominal  cavity  with   the  enlarging  uterus ;  and   in  certain 
conditions   thev  are  dislocated  downward  into  Douglas'  space,  where 
they  may  be  felt  through  the  vagina  as  rounded  and  very  tender  bodies. 

The  folds  of  the  broad  ligament,  between  which  the  ovaries  are 
l)laced,  form  for  them  a  kind  of  loose  mesentery.  Each  of  them  is 
united  to  the  upper  angle  of  the  uterus  by  a  special  ligament  called  the 
utero-oyarian.  This  is  a  rounded  band  of  organic  muscular  fibres 
about  an  inch  jii_len_gth,  continuous  with  the  superficial  muscular  fibres 
of  the  posterior  wall  of  the  uterus,  and  attached  to  the  inner  extremity 
of  the  ovary.  It  is  surrounded  by  peritoneum,  and  through  it  the 
muscular  fibres,  which  form  an  important  integral  part  in  the  structure 
of  the  ovaries,  are  conveyed  to  them.  The  ovary  is  also  attached  to 
the/  fimbriated  extremity  of  the  Fallopian  tube  in  the  maimer  already 
descnbed.  ■■1C~ 

1  His,  Archivfur  Anat.  unci  Phys.,  18S1.  '  Op.  cit. 


74 


onaAys  cosceiiskd  is  parturition. 


The  ovary  is  of  an  irrej^iilar  oval  sliapc  (Fijj.  34),  the  ujijkt  honk-r 
being  convex,  the  h»\\er — tiiroii<ih  whicli  the  vessels  and  nerves  enter — 
beini^  strai<;ht.  (The  anterior  snrfaee,  liUe  that  of  the  uterus,  is  less 
convex  tlian  the  jiosterior.  j  /fhe  outer  extremity  is  more  rounded  and 


A  A.  Ovary  enlarped  under  Menstrual  N'isus. 
B.   Ripe  follicle  projectiug  on  its  surface,    a,  a,  a.  Traces  of  previously  ruptured  folliclee. 

bull)ous  than  the  inner,  which  is  somewhat  pointed  and  eventually  lost 
in  its  proper  licjameut.  By  these  peculiarities  it  is  possible  to  distin- 
guish the  left  from  the  right  ovary  after  they  have  been  removed  from 
the  body.  The  ovary  varies  much  in  size  under  different  circum- 
stances. \On  an  average,  in  adult  life  it  measures  from  one  to  two 
inclies  in  length,  three-quarters  of  an  inch  in  width,  and  about  half  an 
inch  in  thickness.  )  It  increases  greatly  in  size  during  each  menstrual 
period — a  fact  whicli  has  been  demonstrated  in  certain  cases  of  ovarian 
hernia,  in  which  the  protruded  ovary  has  been  seen  to  swell  as  men- 
struation commenced  ;  also  during  pregnancy,  Avhen  it  is  said  to  be 
double  its  usual  size.  After  the  change  of  life  it  atro])]iies,  and 
becomes  rough  and  wrinkled  on  its  surface.  Before  puberty  the  sur- 
face of  the  ovary  is  smooth  and  polished,  and  of  a  whitish  color.  After 
menstruation  commences  its  surface  becomes  scarred  by  the  rupture  of 
the  (iraatian  follicles  (Fig.  34,  a  a),  each  of  which  leaves  a  little  linear 
or  striated  cicatrix  of  a  brownish  color  ;  and  the  older  the  patient  the 
greater  are  the  number  of  these  cicatrices. 

The  sti'ucturc  of  the  ovary  has  been  made  the  subject  of  many 
im])ortant  observations.  It  has  an  external  covering  of  epithelium, 
originally  continuous  with  the  peritoneum,  called  by  some  the  germ-j 
ei)it helium,  in  consequence  of  the  ovules  being  formed  from  it  in  eaM)' 
fretal  life.  In  the  adult  it  is  separated  from  tlie  peritoneum  at  the 
base  of  the  organ  by  a  circular  white  line,  and  it  con>iists  of  cdlumnar 
epithelium,  differing  (tnly  from  the  epithelium  lining  the  Fallopian 
tubes,  with  which  it  is  sometimes  continuous  through  the  attached  fim- 
bria uniting  the  tube  and  the  ovary,  in  being  destitute  of  cilia.  Imme- 
diatelv  beneath  this  coverins;  is  the  dense  coat  known  as  the  tunica 


THE  FEMALE  GENERATIVE  ORflANS.  75 

albtu/inca,  oii  account  of  its  wJiitisli  color.  It  consists  of  short  cou- 
nective-tissue  fibres  arranged  in  lamiuse,  among  whicli  are  interspersed 
fusiform  muscular  fibres.  At  the  point  where  the  vessels,  and  nerves 
enter  the  ovary  this  membrane  is  raisetl  into  a  ridge,  which  is  contin- 
uous M'ith  tlie  utero-ovarian  ligament  and  is  called  the  hilam.  The 
tunica  albuginea  is  so  ultimately  blended  with  the  stroma  of  the  ovary 
as  to  be  inseparable  on  dissection  ;  it  does  not,  however,  exist  as  a  distinct 
lamina,  but  is  merely  the  external  part  of  the  pro})er  structure  of  the 
ovary,  in  which  more  dense  connective  tissue  is  developed  than  elsewhere. 
On  making  a  longitudinal  section  of  the  ovary  (Fig.  35)  it  will  be 
seen  to  be  com])oscd  of  two  parts,  the  more  internal  of  which  is  of  a 
reddish  color  from  the  number  of  vessels  that 
ramify  in  it,  and  is  called  the  medidlarij  or  Fig.  35. 

vascular  zone;  while  the  external,  of  a 
whitish  tint,  receives  the  name  of  the  cortical 
or  parenchymatous  substance.  The  former 
consists  of  loose  connective  tissue  interspersed 
with  elastic  and  a  considerable  number  of 
muscular  fibres.  Accordino;  to  Kou^et^  and 
His,^  the  muscular  structure  forms  the  greater 
part  of  the  ovarian  stroma.  The  latter  de- 
scribes it  as  consisting  essentially  of  inter- 
Avoven  muscular  fibres,  wdiich  he  terms  the 
"fusiform  tissues,"  and  which  he  believes  to  ^"^^^S"^?  (Ifter^Far/e.)^*^''^^ 
be  continuous  with  the  muscular  layers  of 

the  ovarian  vessels.  The  former  believes  that  the  muscular  fasciculi 
accompany  the  vessels  in  the  form  of  sheaths,  as  in  erectile  tissues.  Both 
attribute  to  the  muscular  tissues  an  important  influence  in  the  expulsion 
of  the  ovules  and  in  the  rupture  of  the  Graafian  follicles.  Waldeyer 
and  other  writers,  however,  do  not  consider  it  to  be  so  extensively 
developed  as  Rouget  and  His  believe.  \^he  cortical  substance  is  the 
more  important,  as  that  in  which  the  Graafian  follicles  and  ovules  are 
formed. )  It  consists  of  interlaced  fibres  of  connective  tissue  containing 
a  large  number  of  nuclei.  The  muscular  fibres  of  the  medullary  sub- 
stance do  not  seem  to  penetrate  into  it  in  the  human  female.  In  it  are 
found  the  Graafian  follicles,  which  exist  in  enormous  numbers  from  the 
earliest  periods  of  life  and  in  all  stages  of  development  (Fig.  36). 

The  Graafian  Follicles. — According  to  the  researches  of  Pfliiger, 
AValdeyer,  and  other  German  writers,  the  Graafian  follicles  are  foi'med  iii 
early  foetal  life  by  cylindrical  inflections  of  the  epithelial  covering  of  the 
ovary,  which  dip  into  the  substance  of  the  gland.  These  tubular 
filaments  anastomose  with  each  other,  and  in  them  are  formed  the 
ovules,  which  are  originally  the  epithelial  cells  lining  the  tubes.  Por- 
tions become  shut  off  from  the  rest  of  the  filaments  and  form  the  Graaf- 
ian follicles.  The  ovules,  on  this  view,  are  highly-developed  epithelial/ 
cells,  originally  derived  from  the  surface  of  the  ovary,  and  not  developed! 
in  its  stroma.  These  tubular  filaments  disappear  shortly  after  birth, 
but  they  have  recently  been  detected  by  Slavyansky  ^  in  the  ovaries  of  a 

'  Journal  de  Physiol.,  i,  p.  737.  '  SchuUze's  Arch.f.  Mlkroscop.  Anat.,  1SG5. 

^  Annates  de  Gynec,  Feb.,  1871. 


76 


ORa.iys  LuycEityKD  is  rARTuniTios. 


woman  tliirtv  years  of  age.     Tliese  oUsc  rvatioiis  have  l)eeii  iiKwlificd  hy 
Dr.  Fouli.^.'       lie  reeoj^iiizes  the  ori<;in  of  the  ovules  from  thegerm-epi- 


FiG.  ?.C,. 


Section  through  the  Cortical  Part  of  the  Ovary. 

e.  Surface  epitlieliuin.  s  n.  Ovarian  stroiua.  11.  Larfie-sized  Graafian  follicles.  2  2.  Middlo-eized ;  and 
3  3.  Small-sized  Graafian  fcillicles.  o.  Ovule  witliin  Graafian  follicle,  v  v.  Blood-vosseU  in  the 
stroma,     g.  Cells  of  the  membrana  granulosa,     (After  Turner.) 

thelium  covering  the  surface  of  tlie  ovary,  whicii  is  itself  derived  from  the 
AVolflfiau  body.     He  believes  all  the  ovules  to  be  formed  from  the  germ- 


FlG. 


Vertical  SeClion  throiigh  the  Ovary  of  the  Human  Foetus. 
g  g.  Gcrm-fpitliflium,  witli  o  o.   Developing  ovules  in  it.     »».  Ovarian  stroma  containing  <•<•  c.   Fu.siform 
connective-ti.-isue  corpuscles,     v  v.  C^apillarv  Iilood-ves.sols.      In  the  centre  of  the  figure  an  involution 
of  tlic  Kerni-ei)ithelium  is  shown  :  and  at  tji.-  left  lower  siile  a  primordial  ovule,  with  the  connective- 
tissue  cor]>uschs  arranging  themselves  rouml  it.    (.Vfter  Koulis.) 

epithelium  eor])u.sclc.<  wliicli  become  imbedded  in  the  .-stroma  of  the  ovary 
by  the  outgrowth  of  processes  of  vascular  connective  tissue,  fresh  gerni- 

'  PrnreerUnf/.-^  nf  the  Royal  Soc.  of  Edinb.,  AytrW,  ISTo,  and  Journ.of  Anat.  and  PIdis., 
vol.  xiii.,  1879. 


THE  FEMALE  GENERATIVE  ORGANS.  77 

epithelial  corpuscles  being  constantly  produced  on  the  surface  of  the 
organ  u[)  to  tlie  age  of  two  and  a  half  years,  to  take  the  phiceof  those 
already  imbedded  iu  its  stroma.  He  believes  the  Graafian  follicles  to 
be  formed  by  the  growth  of  delicate  processes  of  connective  tissue 
between  and  around  the  ovules,  but  not  from  tubular  inflections  of  the 
epithelium  covering  tlie  gland,  as  described  by  Waldeyer  (Fig.  37). 
This  view  is  supported  by  the  researches  of  Balfour,'  who  arrives  at  the 
conclusion  that  the  w^hole  egg-containing  part  of  the  ovary  is  really  the 
thickened  germinal  epithelium,  broken  up  into  a  kind  of  meshwork  by 
grow^ths  of  vascular  stroma.  According  to  this  theory,  Pfliiger's  tubular 
filaments  are  merely  trabeculae  of  germinal  ej^ithelium,  modified  cells  of 
which  become  develo])ed  into  ovules. 

The  greater  proportion  of  the  Graafian  follicles  are  only  visible  with 
the  high  powers  of  the  microscope,  but  those  which  are  approaching 
maturity  are  distinctly  to  be  seen  by  the  naked  eye.  The  quantity  of 
these  follicles  is  immense.  Foulis  estimates  that  at  birth  each  human 
ovary  contains  not  less  than  thirty  tliousancl.  No  fresli_follicles  apj)ear 
to  be  fori]Qjed_after_birth],^l  and  as  development  goes  on  some  only  grow, 
anHnby  pressure  on  the  others  destroy  them.  Of  those  that  grow,  of 
course  only  a  few  ever  reach  maturity  ;  they  are  scattered  through  the 
substance  of  the  ovary,  some  developing  in  the  stroma,  others  on  the 
surface  of  the  organ,  where  they  eventually  burst,  and  are  discharged 
into  the  Fallopian  tube. 

A  rijje  Graafian  follicle  has  an  external  investing  membrane  (Fig.  38)i  3 


Diagrammatic  Section  of  Graafian  Follicle. 

1.  Ovum.    2.  Membrana  granulosa.     3.  External  membrane  of  Graafian  follicle.    4.  Its  vessels.    5.  Ova- 
rian stroma.     6.  Cavity  of  Graafian  follicle.    7.  External  covering  of  ovary. 

which  is  generally  described  as  consisting  of  two  distinct  layers :  the 
external,  or  tunica  fibrosa,  highly  vascular  and  formed  of  connective 
tissue;  the  internal,  or  tunica  propria,  composed  of  young  connective 
tissue,  containing  a  large  number  of  fusiform  or  stellate  cells,  and  form- 
ing a  basement  membrane  to  the  epithelial  layer  which  lies  internal  to  it. 
These  layers,  however,  appear  to  be  essentially  formed  of  conden.sed 
ovarian  stroma.     Within  this  capsule  is  the  epithelial  lining,  called  the 

'  F.  M.  Balfour,   "Structure  and  Development  of  Vertebrate  Ovary,"    Quarterly 
Journal  of  Microscopical  Science,  vol.  xviii.,  1878. 


(/ 


78  ORGANS  COXCERXED  IX  rARTriUTfOX. 

memhnDi"  (jrcDtnlot^d,  consistin<:;  of"  coliuiiiiar  ('j)itliclial  colls,  Avliirh, 
according  to  Foiilis,  are  originally  ioniicd  I'roin  tlic  nuclei  of'tlie  fibro- 
nuclear  tissue  of  the  stroma  of  the  ovary,  but  which,  according  to  \\'al- 
deyer  and  Balfour,  are  formed  from  the  germinal  epithelium  itself.  At 
one  })art  of  the  circumference  of  the  ovisac  is  situated  the  ovule,  around 
Avhich  the  epithelial  cells  are  congregated  in  greater  quantity,  constituting 
the  j)ro)ection  known  as  the  discus  pro/if/en(f>.  The  remainder  ot"  the 
cavity  of  the  follicle  is  filled  v.ith  a  small  (juantity  of  transj)arent  fluid, 
the  liquor  fo/iici(li ,  travcviHid  by  three  or  four  minute  bands,  the  retinac- 
ula  of  Barry,'which  are  attached  to  the  opposite  walls  of  the  follicular 
cavity,  and  apparently  serve  the  purpose  of  suspending  the  ovule  and 
maintaining  it  in  a  pro})er  })osition.  In  many  young  follicles  this 
cavity  does  not  at  first  exist,  the  follicle  being  entii'ely  filled  by  the 
ovule.  According  to  Waldeyer,  the  liquor  folliculi  is  formed  by  the 
disintegration  of  the  epithelial  cells,  the  fluid  thus  producL'd  collecting 
and  distending  the  interior  of  the  follicle. 

The  ovule  is  attached  to  some  part  of  the  internal  surface  of  the 
Graafian  follicle.  It  is  a  rounded  vesicle  about  yytt^^^  ^^  ^^^  ^'^^'^'  ^'^ 
diameter,  and  is  surrounded  by  a  layer  of  columnar  cells,  distinct  from 
those  of  the  discus  proligerus,  in  M'hich  it  lies.  It  is  invested  by  a 
transparent  elastic  membrane,  the  zona  pellucida,  or  vitelline  membrane. 
In  most  of  the  lower  animals  the  zona  pellucida  is  perforated  by  nume- 
rous very  minute  pores,  only  visible  under  the  highest  powers  of  the 
microscope ;  in  others  there  is  a  distinct  aperture  of  a  larger  size,  the 
micropyle,  allowing  the  passage  of  the  spermatozoa  into  the  interior  of 
the  ovule.  It  is  possible  that  similar  apertures  may  exist  in  the  human 
ovule,  but  they  have  not  been  demonstrated.  Within  the  zona  pellucida 
some  embryologists  describe  a  second  fine  membrane,  the  existence  of 
which  has  been  denied  by  Bischoff.  The  cavity  of  the  ovule  is  filled 
with  a  viscid  yellow  fluid,  the  yelk,  containing  numerous  granules.  It 
entirely  fills  the  cavity,  to  the  w^alls  of  which  it  is  non-adherent.  In 
the  centre  of  the  yelk  in  young,  and  at  some  portion  of  its  periph- 
ery in  mature  ovules,  is  situated  the  germinal  vesicle,  ^^•hich  is  a 
clear  circular  vesicle,  refracting  light  strongly,  and  about  Jy-th  of  a  line 
in  diameter.  It  contains  a  few  granules,  and  a  nucleolus,  or  germinal 
spot,  which  is  sometimes  double. 

From  within  outward,  therefore,  we  find — 

1.  The  r/ermma^  spot ;  round  this 

2.  The  germinal  vesicle,  contained  in 

i     3.  The  yelk,  which  is  surrounded  by  the 

4.  Zona  pellucida,  with  its  layers  of  columnar  epithelial  cells. 

These  constitute  the  ovule. 

The  ovule  is  contained  in 
f      The   Graafian  follicle,  and  lies  in  that  part  of  its  epithelial  lining 
called  the 

Discus  proligerus,  the  rest  of  the  follicle  being  occupied  by  the  liquor 
folliculi.  Round  these  we  have  the  epithelial  lining  or  membrana  gran- 
ulosa,  and  the  external  coat,  consisting  of  the  tu7iica  propria  and  tlie 
tunica  fibrosa. 

The  vascular  supply  of  the  ovary  is  complex.     The  arteries  enter  at 


THE  FEMALE  GENERATIVE  ORGANS. 


79 


the  hilum,  penetrating  the  stroma  in  a  spiral  curve,  and  are  ultimately 
distributed  in  a  rich  capillary  plexus  to  the  follicles.  The  large  veins 
unite  freely  M'ith  each  other,  and  form  a  vascular  and  erectile  plexus 
continuous  with  that  surrounding  the  uterus,  called  the  bulb  of  the 


Fig.  39. 


Bulb  of  Ovary. 

V.  Uterus.     0.  Ovary  and  utero-ovarian  ligament,    r.  Fallopian  tube.     1.  Utero-ovarian  vein.     2.  Pampin- 
iform ovarian  ple.xus.    3.  Commencement  of  spermatic  vein. 

ovary  (Fig.  39).      Lymphatics  and  nerves  exist,  but  their  mode  of 
termination  is  unknown. 

The  Mammary  Glands. — To  complete  the  consideration  of  the 
generative  organs  of  the  female  we  must  study  the  mammary  glands, 
which  secrete  the  fluid  destined  to  nourish  the  child.  In  the  human 
subject  they  are  two  in  number,  and  instead  of  being  placed  upon  the 
abdomen,  as  in  most  animals,  they  are  situated  on  either  side  of  the 
sternum,  over  the  pectorales  majora  muscles,  and  extendiCfrom  the  third// 
to  the  sixth  ribs,  i)  This  position  of  the  glands  is  obviously  intended  to 
suit  the  erect  position  of  the  female  in  suckling.  They  are  convex 
anteriorly,  and  flattened  posteriorly  where  they  rest  on  the  muscles. 
They  vary  greatly  in  size  in  diiferent  subjects,  chiefly  in  proportion  to 
the  amount  of  adipose  tissue  they  contain.  In  man  and  in  girls 
previous  to  puberty  they  are  rudimentary  in  structure;  w^iile  in  preg- 
nant women  they  increase  greatly  in  size,  the  true  glandular  structures 
becoming  much  hypertrophied.  Anomalies  in  shape  and  position  are 
sometimes  observed.  Supplementary  mammae,  one  or  more  in  number, 
situated  on  the  upper  portion  of  the  mammse,  are  sometimes  met  with, 
identical  in  structure  with  the  normally  situated  glands ;  or,  more  com- 
monly, an  extra  nipple  is  observed  by  the  side  of  the  normal  one.  In^r 
some  races,  especially  the  African,  the  mammae  are  so  large  and  pendu- 
lous that  the  mother  is  able  to  suckle  her  child  over  her  shoulder. 

The  skin  covering  the  gland  is  soft  and  supple,  and  during  preg- 
nancy often  becomes  covered  with  fine  white  lines,  while  large  bine 
veins  may  be  observed  coursing  over.  (Underneath  it  is  a  quautitv  of 
connective  tissue,  containing  a  considerable  amount  of  fat,  which  ex- 
tends beneath  the  true  glandular  structure.  This  is  composed  of  from 
^fiteeu  to  twenty  lobes,  each  of  which  is  formed  of  a  number  of  lobules,,; 
The  lobules  are  produced  by  the  aggregation  of  the  terminal  acini  in'' 
which  the  milk  is  formed.  The  acini  are  minute  cul-de-sacs  opening 
into  little  ducts,  which  unite  with  each  other  until  thev  form  a  larse 


80  oiiGAys  coxrFRxrD  tx  rARrrniTiox. 

duct  for  cacli  lobuU' ;  tlic  diK'ts  ol"  eiuli  l<il»iilc  unite  with  eaoh  other, 
until  they  end  in  a  still  lar<^er  duet  eoinnion  to  each  oi'  the  fifteen 
or  twenty  lobes  into  \\hieh  the  gland  is  divided,  and  eventually  o])en 
on  the  .surface  of  the  nij)ple.  These  terminal  canals  are  known  as  the 
fjaladophorom  duds  (Fig.  40).     They  become  widely  dilated  Xi  they 

Fig.  40. 


1.  Galactophorous  ducts.  2.  Lobiili  of  the  mammary  gland. 

approach  the  nijiple,  so  as  to  form  reservoirs  in  which  milk  is  store<l 
until  it  is  required,  but  when  they  actually  enter  the  nipple  they 
again  contract.  Sometimes  they  give  off  lateral  branches,  but,  accord- 
ing to  Sappey,  they  do  not  anastomose  wath  each  other,  as  some  anato- 
mists have  described.  These  exci'ctory  ducts  are  composed  of  con- 
nective tissue,  with  numerous  elastic  fibres  on  their  external  surface. 
Sappey  and  Robin  dc.'^cribe  a  layer  of  mu.scular  fibres,  chiefly  developed 
near  their  terminal  extremities.  They  are  lined  with  columnar  epithe- 
lium, continuous  with  that  in  the  acini ;  and  it  is  by  the  distension  of 
its  cells  with  fatty  matter,  and  their  subsequent  bursting,  that  the 
milk  is  formed. 

The  nipple  is  the  conical  projection  at  the  summit  of  the  mamma, 
and  if  varies  in  size  in  diiferent  women.  Not  unfrcquently  from  the 
continuous  pre.s.sure  to  wdiich  it  has  been  subjected  by  the  dress,  it  is  so 
depressed  below  the  surface  of  the  skin  as  to  prevent  lactation.  It  is 
generally  larger  in  married  than  in  single  women,  and  increases  in  size 
during  pregnancy.  Its  surface  is  covered  with  numerous  papjllw,  giv- 
ing it  a  rugous  a.s]iect,  and  at  their  bases  the  orifices  of  the  lactif- 
erous ducts  open.  Here  are  also  the  openings  of  numerous  sebaceous 
follicles,  which  secrete  an  unctuous  material  sn]>po.ved  to  ])rotcct  and 
soften  the  integument  during  lactation.  Beneath  the  skin  are  mus- 
cular fibres,  mixed  with  connective  and  elastic  tissues,  vessels,  nerves, 
and  lymphatics.  When  the  nipple  is  irritated  it  contracts  and  hardens, 
and  by  .some  this  is  attributed  to  its  erectile  properties.  The  vascular- 
ity, however,  is  not  grcat,[and  it  contains  no  true  erectile  t issue  j  the 
rhardening  is,  therefore,  due  to  mu.<cular  contraction.  I  Surrounding  the 
nipple  is  the  areola,  of  a  pink  color  in  virgins,  becoming  dark  from  the 
development  of  pigment-cells,  during  pregnancy,  and  always  remaining 
somewhat  dark  after  childbearing.  On  its  surface  are  a  number  of 
prominent  tubercles,  sixteen  to  twenty  in  number,  which  al.so  become 
largely  developed  during  gestation.     They  are  sujjposed  by  some  to 


OVULATION  AND  MENSTRUATION.  81 

secrete  milk  and  to  open  into  the  lactiferous  tubes :  most  probably  they 
are  coiuposed  of  sebaceous  glands  only.  Beneath  the  areola  is  a  circular 
band  of  muscular  fibres,  the  object  of  which  is  to  compress  the  lactifer- 
ous tubes  which  run  through  it,  and  thus  to  favor  the  expulsion  of  their 
contents.  The  manimne  receive  their  blood  from  the  internal  mammary 
and  intercostal  arteries,  and  they  arc  richly  supplied  with  lymphatic 
vessels,  which  open  into  the  axillary  glands.  The  nerves  are  derived 
from  the  intercostal  and  thoracic  branches  of  the  brachial  plexus. 

The  secretion  of  milk  in  women  who  are  nursing  is  accompanied 
by  a  peculiar  sensation,  as  if  milk  were  rushing  into  the  breast,  called 
the  "draught,"  which  is  excited  by  the  efforts  of  the  child  to  suck  and 
by  various  other  causes.  (The  sympathetic  relations  between  the  mammae 
and  the  uterus  are  very  Avell  marked,  as  is  shown  in  the  unimpreg- 
nated  state  by  the  fact  of  the  frequent  occurrence  of  sympathetic 
pains  in  the  breast  iu  connection  with  various  uterine  diseases,  and 
after  delivery  by  the  well-known  fact  that  suction  produces  reflex  con- 
traction of  the  uterus,  and  even  severe  after-pains. 


CHAPTER  III. 

OVULATION  AND  MENSTKUATION. 

Functions  of  the  Ovary. — The  main  function  of  the  ovary  is  to 
supply  the  female  generative  element,  and  to  expel  it,  when  ready 
for  impregnation,  into  the  Fallopian  tube,  along  which  it  passes  into 
the  uterus.  This  process  takes  place  spontaneously  in  all  viviparous 
animals,  and  without  the  assistance  of  the  male.  In  the  lower  animals 
this  periodical  discharge  receives  the  name  of  the  oestrum  or  rut,  at1i 
which  time  only  the  female  is  capable  of  impregnation  and  admits  the 
approach  of  the  male.  In  the  human  female  the  periodical  discharge 
of  the  ovule,  in  all  probability,  takes  place  in  connection  with  menstru- 
ation, which  may  therefore  be  considered  to  be  the  analogue  of  the  rut 
in  animals.  Between  each  menstrual  period  Graafian  follicles  undergo 
changes  which  prepare  them  for  rupture  and  the  discharge  of  their 
contained  ovules.  Afte'r  rupture  certain  changes  occur  which  have  for 
their  object  the  healing  of  the  rent  in  the  ovarian  tissue  through  which 
the  ovule  has  escaped,  and  the  filling  up  of  the  cavity  in  which  it  was 
contained.  This  results  in  the  formation  of  a  peculiar  body  in  the  sub- 
stance of  the  ovary,  called  the  corpus  luteum,  which  is  essentially  modi- 
fied should  pregnancy  occur,  and  is  of  great  interest  and  importance. 
During  the  whole  of  the  childbearing  epoch  the  periodical  matura- 
tion and  rupture  of  the  Graafian  follicles  are  going  on.  If  impregna- 
tion does  not  take  place,  the  ovules  are  discharged  and  lostj,  if  it  does, 
ovulation  is  stopped,  as  a  general  rule,  during  gestation  and  lactation. 

Theory  of  Menstruation. — This,  broadly  speaking,  is  an  outline  of 
the  modern  theory  of  menstruation,  which  was  first  broached  in  the  year 


82  OEGAXS  COXCERXED  TX  rARTmiTIOX. 

1.S21  l)v  Dr.  Power,  and  siil)S('(|iiciitly  clahonitcd  by  Xcgrier,  Bischoff, 
llac'iljorski,  and  many  otlicr  writers.  Altlioii^li  tlie  scc^ueut'C  of  events 
liere  imlicated  may  be  taken  to  be  the  rule,  it  must  be  remembered  that 
it  i.s  one  .subjeet  to  many  exceptions,  for  undoubtedly  ovulation  may 
oceur  without  its  outward  manifestation,  menstruation,  a.s  in  cases  in 
■which  imprejiuatioM  takes  place  during  lactation  or  before  menstruation 
has  been  established,  of  which  many  e\amj)les  are  recorded.  These  ex- 
ceptions have  led  some  nimlern  writers  to  deny  the  ovular  theory  of 
menstruation,  and   their  views  will   require  subsequent  consideration. 

lu  order  to  understiuid  the  subject  properly,  it  will  be  necessary  to 
study  the  sequence  of  events  in  detail. 

Changes  in  the  Graafian  Follicle. — The  changes  in  the  Graafian 
follicle  which  are  associated  with  the  discharge  of  the  ovules  com- 
prise— 1.  3Ia.turatio)t.  xVs  the  period  of  puberty  appi'oaches  a  certain 
number  of  the  Graafian  follicles,  fifteen  to  tAventy  in  number,  increase 
in  size  and  come  near  the  surface  of  the  ovary.  Amongst  these  one 
becomes  especially  developed  preparatory  to  rupture,  and  upon  it  for 
the  time  being  all  the  vital  energy  of  the  o^-ary  seems  to  be  con- 
centrated. A  similar  change  in  one,  sometimes  in  more  than  one, 
follicle  takes  place  periodically  during  the  whole  of  the  childbcaring 
epoch  in  connection  with  each  menstrual  period,  and  an  examination 
of  the  ovary  will  show  several  follicles  in  different  stages  of  develop- 
ment. The  maturing  follicle  becomes  gradually  larger,  until  it  forms  a 
projection  on  the  surface  of  the  ovary  from  five  to  seven  lines  in 
breadth,  but  sometimes  even  as  large  as  a  nut  (Fig.  34).  This  growth 
is  due  to  the  distension  of  the  follicle  by  the  iucrea.sc  of  its  contained 
fluid,  which  causes  it  so  to  press  ujjou  the  ovarian  structures  covering 
it  that  they  become  thinned,  separated  from  each  other,  and  partially 
absorbed,  until  they  eventually  readily  lacerate.  The  follicle  also 
becomes  greatly  congested ;  the  capillaries  coursing  over  it  become 
increased  in  size  ana~loaded  with  blood,  and,  being  seen  through  the 
attenuated  ovarian  tissue,  give  it,  when  mature,  a  bright-red  color. 
At  this  time  some  of  these  distended  capillaries  in  its  inner  coat  lace- 
rate, and  a  certain  quantity  of  blood  escapes  into  its  cavity;.  This 
escape  of  blood  takes  place  before  rupture,  and  seems  to  have  for  its 
principal  olyect  the  increase  of  the  tension  of  the  follicle,  of  which  it 
has  been  termetl  the  menstruation.  Pouchet  was  of  ojiinion  that  the 
blood  collects  behind  the  ovule  and  carries  it  up  to  tin;  surface  of  the 
follicle.  By  these  means  the  follicle  is  more  and  more  distended,  until 
at  last  it  ruptures  (Plate  IL,  Fig.  1),  either  s]>outaneously  or,  it  may  be, 
under  the  stimulus  of  sexual  excitement.  Whether  the  laceration  takes 
place  during,  before,  or  after  the  menstrual  discharge  is  not  yet  posi- 
tively known:  from  the  results  of  post-morten  Qxamination  in  a  num- 
ber of  women  who  died  shortly  before  or  after  the  jieriod,  "NA'illiams 
believes  that  (the  ovules  are  expelled  before  the  monthly  flow  com- 
|mences.M  In  order  that  the  ovule  may  escape,  the  laceration  must, 
of  coui-se^  involve  not  only  the  coats  of  the  Graafian  follicles,  but  also 
the  superincumbent  structures. 

Laceration  seems  to  be  aided  by  the  growth  of  the  internal  layer  of 

'  Proceedings  of  the  Royal  Society,  1875. 


IMah-    III. 


Fig   I. 

ArecavitPy    ruptured    SMd    k(j:>ody   ora.afian 
jfefPiefe',  lUst  dcv&fopintf' ivito  a  Corpus  tu'rcur 


Fie.  2. 

Carpus   iuiii^vn    ten  days   affe-v"  wiensi'iruah'or 


d:?    ^ 


Fig.  3. 

wfiicvi   ftiis   ne.oer   ruptured, 


Fig  4^. 

Corpus   Pute.uvM>  of  eFre^'nanoj _ 


ILLUSTRATIONS   OF  THE  CORPUS  LUTEUM,  CAFTER  DALTON.) 

"5.-jtu.-fls.f.if,.g'?,.c.. 


OVULATION  AND  MENSTRUATION. 


83 


the  follicle,  which  increases  in  thickness  l)ef()re  ru})ture,  and  assumes  a 
characteristic  yellow  color  from  the  number  of  oil-globules  it  then  con- 
tains. It  is  also  greatly  facilitated,  if  it  be  not  actually  produced,  by 
the  turgescence  of  the  ovary  at  each  menstrual  period,  and  l)y  the  con- 
traction of  the  muscular  fibres  in  the  ovarian  stroma.  As  soon  as  the 
rent  in  the  follicular  walls  is  produced,  the  ovule  is  discharged,  sur- 
rounded by  some  of  the  cells  of  the  membrana  granulosa,  and  is  re- 
ceived into  the  fimbriated  extremity  of  the  Fallopian  tube,  which  grasps 
the  ovary  over  the  site  of  the  rupture.  By  the  vibratile  cilia  of  its  epi- 
thelial lining  it  is  then  conducted  into  the  canal  of  the  tube,  along 
Mhicli  it  is  propelled,  partly  by  ciliary  action  and  partly  by  muscular 
contraction  in  the  walls  of  the  tube. 

After  the  ovule  has  escaped  certain  characteristic  changes  occur  in 
the  empty  Graafian  follicle,  which  have  for  their  object  its  cicatrization 
and  obliteration.  There  are  great  diiferences  in  the  changes  which 
occur  when  impregnation  has  followed  the  escape  of  the  ovule,  and  they 
are  then  so  remarkable  that  they  have  been  considered  certain  signs  of 
pregnancy.  They  are,  however,  differences  of  degree  rather  than  of 
kind.     It  will  be  well,  however,  to  discuss  them  separately. 

As  soon  as  the  ovule  is  discharged  the  edges  of  the  rent  through 
which  it  has  escaped  become  agglutinated  by  exudation,  and  the  follicle 
shrinks,  as  is  generally  believedTlBy  the  inherent  elasticity  of  its  internal 
coat,  but,  according  to  Robin,  who  denies  the  existence  of  this  coat,  from 
compression  by  the  musular  fibres  of  the  ovarian  stroma.  In  proportion 
to  the  contraction  that  takes  place  the  inner  layer  of  the  follicle,  the 
cells  of  which  have  become  greatly  hypertrophied  and  loaded  with  fat- 
granules  previous  to  rupture,  is  thrown  into  laumerQUg, folds  (Plate  II.| 
Fig.  2).  The  greater  the  amount  of  contraction  the  deeper  these  folds 
become,  giving  to  a  section  of  the  follicle  an  appearance  similar  to  that 
of  tlie  convolutions  of  the  brain  (Fig.  41).  ^These  folds  in  the  human 
subject  are  generally  of  a  bright-yellow 
color,  but  in  some  of  the  mammalia  they 
are  of  a  deep  red.  j  The  tint  was  formerly 
ascribed  by  Raciborski  to  absorption  of  the 
coloring  matter  of  the  blood-clot  contained 
in  the  follicular  cavity — a  theory  he  has 
more  recently  abandoned  in  favor  of  the 
view  maintained  by  Coste,  that/it  is  due  to 
the  inherent  color  of  the  cells  of  the  lin- 
ing membrane  of  the  follicle,  which, 
though  not  well  marked  in  a  single  cell, 
becomes  very  apparent  en  ma.'^.se.J  The  ex- 
istence of  a  contained  blood-clot  is  also 
denied  by  the  latter  physiologist,  except 
as  an  unusual  pathological  condition;  and  secti 
he  describes  the  cavity  as  containing  a 
gelatinous  and  plastic  fluid  which  be- 
comes absorbed  as  contraction  advances.  (The  more  recent  researches 
of  Dalton,^  however,  show  the  existence  of  a  central  blood-clot  in  the 

'  "  Report  on  the  Corpus  Luteum,"  American  Gyncec.  Trails.,  1877,  vol.  ii.  p.  111. 


Fig 


Ovary.  sh(i\vin>jf  corims 
luteum  three  weeks  after  lueustru- 
ation.    (After  Dalton.) 


84  ORGANS  CONCERNED  IN  PARTURITION. 

cavity  of  the  follicle;  and  he  coiisidei'S  its  occa.sional  absence  to  be  cou- 
''uected  with  disturbance  or  cessation  of  the  menstrual  iuuction.j  (The 
Ifolds  into  which  the  membrane  has  been  thrown  continue  to  inci'ease  in 
)size,  from  the  proliferation  of  their  cells,  until  they  unite  and  become 
[adherent,  and  eventually  till  the  follicular  cavity.'j  J>y  the  time  that 
another  Graafian  follicle  is  matured  and  ready  Ibr  rupture  the  diminu- 
tion has  advanced  considerably,  and  the  empty  ovisac  is  reduced  to  a 
very  small  size.  The  cavity  is  now  nearly  obliterated,  the  yellow 
color  of  the  convolutions  is  altered  into  a  whitish  tint,  and  on  section 
the  cor{)us  luteuni  has  the  appearance  of  a  compai-t  white  stellate 
cicatrix,  which  generally  disappears  in  less  than  forty  davs  from  the 
j)eriod  of  rupture.  The  tissue  of  the  ovary  at  the  site  of  laceration 
also  shrinks,  and  this,  aidetl  by  the  contraction  of  the  follicle,  gives  rise 
to  one  of  those  permanent  pits  or  depressions  which  mark  the  surface  of 
the  adult  ovary.  Slavyansky'  has  shown  that  only  a  few  of  the  im- 
mense number  of  Graafian  follicles  undergo  these  alterations.  The 
greater  proportion  of  them  seem  never  to  discharge  their  ovules,  but, 
after  increasing  in  size,  undergo  retrogressive  changes  exactly  similar  in 
their  nature,  but  to  a  much  less  extent,  to  those  which  result  in  the 
formation  of  a  corpus  luteum.  The  sites  of  these  may  afterward  be 
seen  as  minute  striae  in  the  substance  of  the  ovary. 
\  Should  pregnancy  occur,  all  the  changes  above  described  take  place  ; 
but,  inasmuch  as  the  ovary  partakes  of  the  stimulus  to  which  all  the 
generative  organs  are  then  subjected,  they  are  much  more  marked  and 
apparent  (Plate  11^  Fig.  4).  Instead  of  contracting  and  disapjjcaring 
in  a  few  weeks,  the  corpus  luteum  continues  to  grow  until  the  third  or 
fourth  month  of  pregnancy ;  the  folds  of  the  inner  layer  of  the  ovisac 
become  large  and  fleshy  anct  permeated  by  numerous  capillaries,  and 
ultimately  become  so  firmly  united  that  the  margins  of  the  convolutions 
thin  and  disappear,  leaving  only  a  firm  fleshy  yellow  mass,  averaging 
from  1  to  1|  inches  in  thickness,  which  surrounds  a  central  cavity,  often 
containing  a  whitish  fibrillated  structure,  believed  to  be  the  remains  of 
a  central  blood-clot.  This  was  erroneously  supposed  by  Montgomery  to 
be  the  inner  layer  of  the  follicle  itself,  and  he  conceived  the  yellow  sub- 
stance to  be  a  new  formation  between  it  and  the  external  layer ;  Avhile 
Robert  Lee  thought  it  was  placed  external  to  both  the  external  and 
internal  layers. 

Between  the  third  and  fourth  months  of  jircgnancy,  when  the  corpus 
luteum  has  attained  its  maximum  of  development  (Fig.  42),  it  forms  a 
firm  ])ro)ection  on  the  surface  of  flic  ovary,  averaging  about  one  inch  in 
lengtli  and  I'atlicr  more  than  half  an  inch  in  breacltli.  After  this  it 
conmiences  to  atrophy  (Fig.  4.">),  the  fat-cells  become  absorbed,  and  the 
capillaries  disappear.  Cicatrization  is  not  complete  until  from  one  to 
two  months  after  delivery. 

On  account  of  the  marked  a]-)pcarance  of  the  corpus  luteum  it  was 
formerly  considered  to  be  an  infallible  sign  of  pregnancy;  and  it  was 
distinguished  from  the  corpus  luteum  of  the  non-pregnant  state  by  being 
called  a  "true"  as  oj)posed  to  a  "false"  corpus  luteum.  From  what 
has  been  said,  it  will  be  obvious  that  this  designation  is  essentially 

>  Archil:  de  Phys.,  M;ircli,  1874. 


OVULATIOX  AND  MEXSJ'RUATIOX. 


85 


wrong,  as  the  (lifference  is  one  of  degree  only.  (l)alton'  ai)plics  the 
term  "  false  corpus  liiteum"  to  a  degenerated  condition  sometimes  met 
with  in  an  unruptured  Graafian  follicle,  consistinj^  in  reabsorption  of 
its  contents  and  thickening  of  its  walls  (Plate  Ilf,  Fig.  3).\   It  differs 


Fig.  42. 


Fig.  43. 


Corpus  Lnteum  of  the  Fourth  Month  of 
Pregnancy.    (After  Dalton.) 


Corpus  Luteum  of  Pregnancy  at 
Term.    (After  Dalton.) 


from  the  "  true  "  corpus  luteum  in  being  deeply  seated  in  the  substance 
of  the  ovary,  in  having  no  central  clot,  and  in  being  unconnected  with 
a  cicatrix  on  the  surface  of  the  ovary.  Xor  do  obstetricians  attach  by 
any  means  the  same  importance  as  they  did  formerly  to  the  presence  of 
the  corpus  luteum  as  indicating  impregnation  ;  for,  even  when  well 
marked,  other  and  more  reliable  signs  of  recent  delivery,  such  as 
enlargement  of  the  uterus,  are  sure  to  be  present,  especially  at  the  time 
when  the  corpus  luteum  has  reached  its  maximum  of  development ; 
while  after  delivery  at  term  it  has  no  longer  a  sufficiently  characteristic 
ap]:)earauce  to  be  depended  on. 

Menstruation. — By  the  term  menstrucdion  (catamenia,  periods,  etc.) 
is  meant  the  periodical  discharge  of  blood  from  the  uterus  which  occurs, 
in  the  healthy  woman,  every  lunar  month,  except  during  pregnancy  and 
lactation,  when  it  is,  as  a  rule,  suspended. 

The  first  appearance  of  menstruation  coincides  with  the  establishment 
of  puberty,  and  the  physical  changes  that  accompany  it  indicate  that  the 
female  is  capable  of  conception  and  childbearing,  although  exceptional 
cases  are  recorded  in  which  pregnancy  occurred  before  menstruation  had 
begun.  In  temf)erate  climates  it  generally  commences  between  the 
f()ui:teenth  and  .sixteenth  years,  the  largest  number  of  cases  being  met 
wiTTTTn  the  fifteenth  year. '  This  rule  is  subject  to  many  excejitions,  it 
being  by  no  means  very  rare  for  menstruation  to  become  established  as 
early  as  the  tenth  or  eleventh  year  or  to  be  delayed  until  the  eighteenth 
or  twentieth.  Beyond  these  physiological  limits  a  few  cases  are  from 
time  to  time  met  with  in  which  it  has  begun  in  early  infancy  or  not 
until  a  comparatively  late  period  of  life. 

Influence  of  Climate,  Race,  etc. — Various  accidental  circumstances 

^  Op.  cit.,  p.  64. 


^;8G  ORCAXS  COXCERXED  TX  rARTJ'PJTJON. 

have  much  to  do  with  its  estabhsh incut.  As  a  rule,  it  occurs  souiewhat 
carlk'r  iu  tropical,  and  later  in  very  cold  than  in  temperate,  climates. 
Tile  inlhiencc  of  climate  has  been  unduly  exajrgerated.  It  used  to  he 
ot'iicraliy  stated  that  in  the  Arctic  re<i;ioi)S  women  ilid  not  menstruate 
until  they  were  of  mature  ati;e,  and  that  in  the  tro[)ics  jrirls  of  ten  or 
twelve  years  of  aj2;e  did  so  hal)itually.  1'he  researches  of  Robertson  of 
^lanchester '  tirst  showed  that  the  j;enerally  received  opinions  were  erro- 
neous, and  the  collection  of  a  larjje  number  of  statistics  has  corroborated 
his  opinion.  There  can  be  no  doubt,  however,  that  a  lar<i:i'r  j)ro]wrtion 
of  girls  menstruate  early  in  warm  climates.  J<julin  iound  that  in 
tro{)ical  climates,  out  of  1G.")5  cases  the  largest  propoi-tion  began  to 
menstruate  between  the  twelfth  and  thirteenth  years,  so  that  there  is  an 
average  difference  of  more  than  two  years  betweeen  the  i>eriotl  of  its 
establishment  in  the  tropics  and  in  temperate  countries.  Harris'  states 
that  among  the  Hindoos  1  to  2  per  cent,  menstruate  as  early  as  nine  years 
of  age ;  3  to  4  jier  cent,  at  ten  ;  8  per  cent,  at  eleven  ;  and  25  per  cent, 
at  twelve ;  while  in  Loudon  or  Paris  probably  not  more  than  1  girl  in 
1000  or  1200  does  so  at  nine  years.  The  converse  holds  true  Mith 
regard  to  cold  climates,  although  we  are  not  iu  possession  of  a  sufficient 
number  of  accurate  statistics  to  draw  very  reliable  conclusions  on  this 
point ;  but  out  of  4715  cases,  including  returns  from  Denmark,  Norway 
and  Sweden,  Russia,  and  Labrador,  it  Avas  found  that  menstruation  was 
established  on  an  average  a  year  later  than  in  more  temperate  countries. 
T^t  is  probaljle  that  the  mere  influence  of  temjierature  has  much  to  do  iu 
producing  these  differences,  but  there  are  other  factors  the  action  of 
■which  must  not  be  overlooked.  Raciborski  attributes  considerable  im- 
portance to  the  effect  of  race ;  and  he  has  quoted  Dr.  Webb  of  Calcutta 
to  the  effect  that  English  girls  in  India,  although  subjected  to  the  same 
climatic  influence  as  the  Indian  races,  do  not,  as  a  rule,  menstruate  earl- 
ier than  in  England  ;  Mhile  iu  Austria  girls  of  the  ^Magyar  race  meu- 
^struate  considerably  later  than  those  of  German  ])arentage.^  The^ur- 
ilQundings  of  girls  and  their  manner  of  education  and  living  have 
probably  also  a  marked  influence  in  promoting  or  retarding  its  establish- 
ment. Thus,  it  will  commence  earlier  in  the  children  of  the  rich,  who 
are  likely  to  have  a  highly-developed  nervous  organization,  and  are 
habituated  to  luxurious  living  and  a  premature  stimuhition  of  the  mental 
faculties  by  novel-reading,  society,  and  the  like;  while  amongst  the 
hard-worked  poor  or  in  girls  brought  up  in  the  countiy  it  is  more  likely 
to  begin  later.  Premature  sexual  excitement  is  said  also  to  favor  its 
early  appearance,  and  the  influence  of  this  among  the  factory-girls  of 
Manchester,  who  are  exposed  in  the  course  of  their  work  to  the  tempta- 
tions arising  from  the  promiscuous  mixing  of  the  sexes,  has  been  pointed 
out  by  Dr.  Clay.* 

[Precocious  Physical  "Woinanhood. — We  emphasize  the  term 
''  physical,"  because  in  a  mental  and  moral  sense  the  subjects  are  for- 
tunately, with  rare  exceptions,  only  children  in  years  and  tastes.     Pre- 

»  Edin.  Med.  and  Surg.  Journ.,  1832. 

■■'  Amer.  Journ.  of    Obstet.,   1870-71,   vol.   iii.   p.    611:    R.  P.  Harris,   "On   Early 
Pubertv." 

*  Op.  cit.,  p.  227.  *  Brit.  Record  oj  Obstd.  Med.,  vol.  i. 


OVULATION  AND  MENSTRUATION.  87 

cociously  developed  girls  are,  as  a  rule,  of  very  unusual  size  for  their 
years,  and  usually  enjoy  good  health,  while  precoeity  in  male  children  is 
apt  to  be  associated  with  senii-idioey  and  cpile[)sy.  Where  menstruation 
begins  in  the  iirst  year,  the  girl  may  at  three  or  four  years  of  age  pre- 
sent the  evidences  of  puberty  in  the  appearance  of  pubic  and  axillary 
hair,  rounded  mammae,  and  a  broad  pelvis,  associated  with  well-rounded 
arms  and  legs  and  a  strength  and  height  much  beyond  her  years.  In 
three  children  l)orn  in  this  State,  these  characteristics  were  marked 
resj)ectively,  at  four  and  a  half  years,  five,  and  six.  The  five-year-old 
girl  was  a  beautifully  formed  miniature  woman,  and  the  one  of  six  was 
large,  fat,  and  had  the  developed  features  of  twice  her  age ;  still,  she  was 
only  a  child  in  tastes,  and  as  such  devoted  to  her  dolls  and  toys.  The 
sexual  passion  is  very  rarely  a  marked  characteristic  in  such  subjects, 
as  it  is  in  the  other  sex,  and  hence  the  ability  to  procreate  has  rarely 
been  tested ;  but  occasionally  in  the  lower  classes  pregnancy  has 
occurred  at  an  early  age. 

The  youngest  English  mother  on  record  was  nine  years  seven  months  | 
and  nine  days  old  when  Mr.  Henry  Dodd  of  Billingtou,  York,  who 
was  present  at  her  birth,  delivered  her  of  a  seven-pound  healthy  child, 
after  a  labor  of  six  hours,  on  March  17,  1881.  She  commenced  to 
menstruate  at  twelve  months,  and  became  pregnant  about  six  weeks 
before  she  was  nine  years  old.^ 

The  youngest  American  mother  became  such  at  ten  years  and  thirteen  | 
days,  giving  birth  to  a  child  of  seven  and  three-quarter  pounds.  She 
also  menstruated  at  one  year,  and  at  the  time  of  her  labor  was  4  ft.  7 
inches  in  height  and  weighed  100  pounds.  The  case  was  reported  by 
Dr.  Rowlett  of  Kentucky.^  A  still  younger  mother  was  reported  by 
Schmith  more  than  a  century  ago.  The  child  began  to  menstruate  at 
two  years,  and  when  eight  years  and  ten  months  old  bore  a  dead  foetus 
which  was  thought  by  its  development  to  have  reached  its  full  term. 
The  mother  had  the  mammae  and  pubes  of  a  girl  of  seventeen.^     Ed.] 

Changes  Occurring  at  Puberty. — The  first  appearance  of  men-  K 
struation  is  accompanied  by  certain  well-marked  changes  in  the  female 
system,  on  the  occurrence  of  which  we  say  that  the  girl  has  arrived  at 
the  period  of  puberty.  The  pubes  become  covered  with  hair,  the^'breasts 
enlarge,  the  pelvis  assumes  its  fully-developed  form,  and  the  general 
contour  of  th^body  fills  out.  The  mental  CLualitiesalso  alter :  the  girl 
becomes  more  shy  and  retiring,  and  her  whole  bearing  indicates  the 
change  that  has  taken  place.  The  menstrual  discharge  is  not  estab- 
lished regularly  at  once.  For  one  or  two  months  there  may  be  only 
premonitory  symptoms — a  vague  sense  of  discomfort,  pains  in  the 
breasts,  and  a  feeling  of  weight  and  heat  in  the  back  and  loins.  There 
then  may  be  a  discharge  of  mucus  tinged  with  blood,  or  pure  blood, 
and  this  may  not  again  show  itself  for  several  months.  Such  irregu- 
larities are  of  little  consequence  on  the  first  establishment  of  the  func- 
tion, and  need  give  rise  to  no  apprehension. 

Duration. — As  a  rule,  the  discharge  recurs  every  twenty-eight  days, 

\}  Barnes'  Obstetric  Medicine  and  Surgery.'] 

[^  Tranniilvania  Med.  Journ.,  vol.  vii.  p.  447.] 

[^  Sue's  Essais  hidoriques,  Paris,  1779,  vol.  ii.  p.  344.] 


f 


88  ORGANS  CONCERNED   L\  PARTURITION. 

and  with  some  women  with  such  roj^uhirity  that  they  can  foretell  its 
appearance  almost  to  the  hour.  The  rule  is,  however,  subject  to  very 
jj;reat  variations.  It  is  by  no  means  uncommon,  and  strictly  within  the 
limits  ul"  health,  for  it  to  api)ear  every  twentieth  day,  or  even  with  less 
intcival  ;  while  in  other  cases  as  much  as  six  weeks  may  habitutdly 
intervene  i)etweeu  two  periods.  The  period  of  incurrence  mav  also 
vary  in  the  same  subject.  I  am  actpiainted  with  patients  who  some- 
times only  have  twenty-eight  days,  at  others  as  many  as  forty-eight 
days,  between  their  periods,  without  their  health  in  any  way  sul!ering. 
Joulin  mentions  the  case  of  a  lady  who  only  menstruated  two  or  three 
times  in  the  year,  and  whose  sister  had  the  same  jx'culiarity. 

The  duration  of  the  period  varies  in  ditierent  women  and  in  the 
same  woman  at  different  times.  In  this  country  its  average  is  four  or 
five  dm's.  while  in  France,  Dubois  and  Brierre  de  Boismont  fix  eight 
days  as  the  most  usual  length.  Some  women  are  only  unwell  for  a  few 
hours,  while  in  others  the  period  may  last  many  days  beyond  the  aver- 
age without  being  considered  abnormal. 

The  quantity  of  blood  lost  varies  in  different  women.  Hipjxici-ates 
puts  it  at  oxviij,  which,  however,  is  nuich  too  high  an  estimate.  Arthur 
Farre  thiid<sWiat  from  .sij  to  siij  is  the  full  amount)  of  a  healthy 
period,  and  tlm  the  quantity  cannot  habitually  exceed  tins  without  ])ro- 
ducing  serious  constitutional  effects.  Rich  diet,  luxurious  living,  and 
anything  that  unhealthily  stimulates  the  body  and  mind  will  have  an 
injurious  effect  in  increasing  the  flow  ;  which  is  therefore  less  in  hard- 
worked  countrywomen  than  in  the  Ijcttcr  classes  and  residents  in  towns. 

It  is  more  abundant  in  warm  climates,  and  our  countrywomen  in 
India  habitually  menstruate  over-profusely,  becoming  less  abundantly 
unwell  when  they  return  to  England.  The  same  observation  has  been 
made  with  regard  to  American  Avomen  residing  in  the  Gulf  States,  who 
improve  materially  by  removing  to  the  Lake  States.  Some  women 
appear  to  menstruate  more  in  summer  than  in  winter.  I  am  acquainted 
with  a  lady  who, spends  the  winter  in  St.  Petersburg,  where  her  periods 
last  eight  or  ten  days,  and  the  summer  in  England,  where  they  never 
exceed  four  or  five.  The  difference  is  probably  due  to  the  effect  of  the 
over-heated  rooms  in  which  she  lives  in  Russia. 

The  daily  loss  is  not  the  same  during  the  continuance  of  the  period. 
It  generally  is  at  first  slight,  and  gradually  increases  so  as  to  be  most 
profuse  on  the  second  or  third  day,  and  as  gradually  diminishes.  Toward 
the  last  days  it  sometimes  disappears  for  a  few  hours,  and  then  comes  on 
again,  and  is  apt  to  recur  under  any  excitement  or  emotion. 

As  the  menstrual  fluid  escajies  from  the  uterus  it  consists  of  pure 
blood,  and  if  collected  through  the  sj)ceulum  it  coagulates.  The  ordi- 
nary menstrual  fluid  does  not  coagulate  unless  it  is  excessive  in  amount. 
Various  exj)lanations  of  this  fact  have  been  given.  It  was  formerly 
supposed  either  to  contain  no  fibrin  or  an  unusually  small  amount. 
Retzius  attriJMites  its  non-coagulation  to  the  presence  of  free  lactic  and 
phosphoric  acids.  I  The  true  explanation  was  first  given  by  Mandl,  who 
proved  that/feven  *  mall  quantities  of  i^us  or  miicus  in  blood  were  suf- 
jficient  to  keep  the  fibrin  in  solution  ;  and  nuicus  is  always  jn'esent  to 
greater  or  less  amount  in  the  secretions  of  the  cervix  and  vagina,  which 


ecom-  ^-  \^    jf^ 
orbed,  \J  ^  S 
nstm-       ^^ 
rfih'on         ^ 


OVULATION  AND  MENSTRUATION.  89 

mix  with  the  menstrual  blood  in  its  passage  through  the  genital  tract.!  ^ 

If  the  amount  of  blood  be  excessive,  however,  the  mucus  present  isl  .    J 

insufficient  in  quantity  to  produce  this  effect,  and  coagula  are  then;      y\»  > 
formed.    *  n^  r^jf 

On  mia:Dscopic  examination  the  menstrual  fluid  exhibits  blood-cor-^yr  /" 
puscles,  m ucus-corpuscl es ,  and  a  considerable  amount  of 'Epithelial 
scales,  the  last  being  the  debris  of  the  epithelium  lining  the  uterine 
cavity.  (  According  to  Virchow,  the  form  of  the  epithelium  often  proves  j 
that  it  comes  from  the  interior  of  the  utricular  glands.^  The  color  of 
the  blood  is  at  first  dark,  and  as  the  period  progresses  it  generally 
becomes  lighter  in  tint.     In  women  who  are  in  bad  health  it  is  often  / 

very  pale.     These  differences  doubtless  depend    upon  the  amount  of      V^jT, 
mucus  mingled  with  it.     The  menstrual  I  blood  has  always  a  character- T.  vy^     '\ 
istic  faint  and  heavy  qdor^i  M'hich  is  analogous  to  that  which  is  so  dis-  ^  ^ 

tinct  in  the  lower  animals  during  the  rut.     Raciborski  mentions  a  lady  ^ 

who  was  so  sensitive  to  this  odor  that  she  could  always  tell  to  a  certainty  J 

when  any  woman  was  menstruating.  (  It  is  attributed  either  to  decom-  ,-  \^  ^, 
posing  mucus  mixed  with  the  blood,  which,  when  partially  absorbed, 
may  cause  the  peculiar  odor  of  the  breath  often  perceptible  in  menstru- 
ating women,  or  to  the  mixture  with  the  fluid  of  the  sebaceous  secretion 
from  the  glands  of  the  vulva. ')  It  probably  gave  rise  to  the  old  and 
prevalent  prejudices  as  to  the  deleterious  properties  of  menstrual  blood, 
which,  it  is  needless  to  say,  are  altogether  without  foundation. 

It  is  now  universally  admitted  that  thefsource  of  the  menstrual  blood  \\ 
is  the  mucous  membrane  lining  the  interior  of  the  uterus,)for  the  blood 
may  be  seen  oozing  through  the  os  uteri  by  means  of  the  speculum  and 
in  cases  of  procidentia  uteri;  while  in  cases  of  inverted  uterus  it  may  be 
actually  observed  escaping  from  the  exposed  mucous  membrane  and  col- 
lecting in  minute  drops  upon  its  surface.  (^During  the  menstrual  nisus 
the  whole  mucous  lining  becomes  congested  to  such  an  extent  that,  in 
examining  the  bodies  of  women  who  have  died  during  menstruation,  it 
is  found  to  be  thicker,  jlarger,  and  thrown  into  folds,  so  as  to  completely 
fill  the  uterine  cavity.  The  capillary  circulation  at  this  time  becomes 
very  marked,  and  the  mucous  membrane  assumes  a  deep-red  hue,  the 
network  of  capillaries  surrounding  the  orifices  of  the  utricular  glands 
being  especially  distinct.  These  facts  have  an  unquestionable  connec- 
tion with  the  production  of  the  discharge,  but  there  is  much  difference 
of  opinion  as  to  the  precise  mode  in  which  the  blood  escapes  from  the^^ 
vessels.  Coste  believed  that  the  blood  transudes  through  the  coats  of  the  -* 
capillaries  without  any  laceration  of  their  structure.  ITarre  inclines  to 
the  hypothesis  that  the  uterine  capillaries  terminate  by  open  mouths,  the 
escape  of  blood  through  these  between  the  menstrual  periods  being  ]ire- 
vented  by  muscular  contraction  of  the  uterine  walls.  Pouchet  believed 
that  during  each  menstrual  e])oeh  the  entire  mucous  membrane  is  broken 
down  and  cast  off  in  the  form  of  minute  shreds,  a  fresh  mucous  mem- 
brane being  developed  in  the  interval  between  two  periods.  During 
this  process  the  cajullary  network  would  be  laid  bare  and  ruptured,  and 
the  escape  of  blood  readily  accounted  for.  Tyler  Smith,  who  adoj>ted 
this  theory,  states  that  he  lias  frc^quently  seen  the  uterine  nuicous  mem- 
brane in  women  who  have  died  durino-  menstruation  in  a  state  of  disso- 


90  ORGANS  CONCERNED  IX  PARTURITION. 

lutioii,  witli  the  ln'okon  looj)s  of  the  capillaries  ex[)ose(l.  Tlie  |>lie- 
noiueiui  atteiuliiiji-  the  so-ealled  inenilmiiioii.s  clysineiiorrhd'a,  in  whieh 
the  mucous  membraue  is  thrown  oii' in  shreds  or  as  a  cast  of  the  uterine 
cavity — the  nature  of  which  Avas  first  })()inted  out  by  8inij)S(»n  and 
Oldham — have  been  suj)posed  to  corroborate  this  thc(»ry.  This  view  is, 
in  the  main,  corroborated  by  the  recent  researches  of  Kni>;elmann,' 
\\  illiams,"  and  others.  (^AN'illiams  describes  the  mucous  linintr  of  the 
-uterus  as  undergoing  a  fatty  degeneration  before  each  period,  which 
'commences  near  the  inner  os,  and  extends  over  the  whole  mucous  mem- 
brane and  down  to  the  muscular  wall.  This  seems  to  bring  on  a  certain 
amount  of  muscular  contraction,  which  drives  the  blood  into  the  capil- 
laries of  the  mucosa,  and  these,  having  become  degenerated,  readily 
rupture  and  jiermit  the  escape  of  the  blood.)  The  mucous  mendjrane 
.now  rapidly  disintegrates,  and  is  cast  oii'  in  shreds  with  the  menstrual 
discharge,  in  which  masses  of  epithelial  cells  may  always  be  detected. 
Engehiiaun,  however,  holds  that  the  fatty  degeneration  is  limited  to  the 
superficial  layers,  and  that  a  portion  only  of  the  epithelial  investment  is 
thrown  off.  ^Vs  soon  as  the  period  is  over,  the  formation  of  a  new 
mucous  membrane  is  begun,  Avhich  arises  either  from  proliferation  of 
the  elements  of  the  muscular  coat  itself,  or  from  the  proliferation  of 
the  epithelial  cells  lining  the  bases  of  the  uterine  glands  which  remain 
imbedded  in  the  muscular  tissue  after  the  mucous  membrane  has  been 
thrown  off,  and  at  the  end  of  a  week  the  whole  uterine  cavity  is  lined 
l)y  a  thin  mucous  membrane.  This  grows  until  the  advent  of  another 
])eriod,  when  the  same  degenerative  changes  occur  unless  imjiregnation 
has  taken  place,  in  which  case  it  becomes  further  developed  into  the 
decidua.  LoewenthaP  believes  that  the  meustral  decidua  is  produced 
by  the  imbedding  of  an  ovum  in  the  lining  membrane  of  the  uterus, 
which,  if  imju'cgnation  occurs,  is  develo])ed  into  the  decidua  of  preg- 
nancy. If  conception  does  not  take  place,  the  ovum  dies,  and  this  is 
followed  by  the  degeneration  and  expulsion  of  the  menstrual  decidua, 
accompanied  by  a  flow  of  blood,  which  is  the  menstrual  discharge. 

Theory  of  Menstruation. — That  ^there  is  an  intimate  comicction 
between  ovulation  and  menstruation)  is  admitted  by  most  physiologists, 
and  it  is  held  by  many  that  the  determining  cause  of  the  discharge  is 
the  periodic  maturation  of  the  Graafian  follicles.  There  is  abundant 
evidence  of  this  connection,  for  we  know  that  when,', at  the  change  of 
life,  the  Graafian  follicles  cease  to  develop,  menstruation  is  arrested) 
andi.when  the  ovaries  are  removed  by  operation,  of  which  there  are  now 
numerous  cases  on  record,  or  when  they  are  congenitally  absent,  men- 
struation does  not  generally  take  ])lace. )  A  few  cases,  however,  have 
been  observed  in  which  menstruation  contimi(>d  after  doulile  ovari- 
otomy, or  the  removal  of  the  ovaries  bv  Battev's  operation,  and  these 
have  been  used  as  an  argument  by  those  ]>hysiologists  who  doul)t  the 
ovular  theory  of  menstruation.     Slavyansky  has  particularly  insisted  ou 

*  Amrricfin  Journal  of  Ohs^tetrirs,  lS7o-7G,  vol.  viii.  p.  30. 

*  "On  tlie  Stniftiire  of  the  Mucous  Menibrniie  of  the  Uterus,"  OhMet.  Journ., 
1875-76,  vol.  iii.  p.  4%. 

^  Arch./.  Gyn.,  Bd.  xxiv.  Hft.  2,  S.  1G9:  "  Eine  neue  Deutung  des  Menstruations- 
Prozess." 


OVULATION  AND  MENSTRUATION.  91 

such  cases,  which,  however,  are  probably  susceptible  of  explanation. 
It  may  be  that  the  habit  of  menstruation  may  continue  for  a  time  even 
after  the  removal  of  the  ovaries ;  and  it  has  not  been  shown  that  men- 
struation has  continued  permanently  after  double  ovariotomy,  although 
it  certainly  has  occasionally,  although  quite  exceptionally,  done  so 
for  a  time.  It  is  possible,  also,  that  in  such  cases  a  small  portion  of 
ovarian  tissue  may  have  been  left  unremoved,  sufficient  to  carry  on 
ovulation.  Roberts,  a  traveller  quoted  by  Depaul  and  Gueniot  in  their 
article  on  menstruation  in  the  Bidiorinaire  des Sciences medicales,  relates 
that  in  certain  parts  of  Central  Asia  it  is  the  custom  to  remove  both 
ovaries  in  young  girls  who  act  as  guards  to  the  harems.  These  women, 
known  as  "hedjeras,"  subsequently  assume  much  of  the  virile  type  and 
never  menstruate.  The  same  close  connection  between  ovulation  and 
the  rut  of  animals  is  observed,  and  supports  the  conclusion  that  the  rut 
and  menstruation  are  analogous.  The  chief  difference  between  ovulation 
in  man  and  the  lower  animals  is  that  in  the  latter  the  process  is  not 
generally  accompanied  by  a  sanguineous  flow.  To  this  there  are  excep- 
tions, for  in  monkeys  there  is  certainly  a  discharge  analogous  to  men- 
struation occurring  at  intervals.  Another  point  of  distinction  is  that  in 
animals  connection  never  takes  place  except  during  the  rut,  and  that  it 
is  then  only  that  the  female  is  capable  of  conception  ;  while  in  the 
human  race  conception  only  occurs  in  the  intervals  between  the  periods. 
This  is  another  argument  brought  against  the  ovular  theory,  because,  it 
is  said,  if  menstruation  depend  on  the  rupture  of  a  Graafian  follicle  and 
the  emission  of  an  ovule,  then  impregnation  should  only  take  place 
during  or  immediately  after  menstruation.  iCoste  explains  this  by  sup- 
jiosing  that  it  is  the  maturation  and  not  the  rupture  of  the  follicle  which  , 
determines  the  occurrence  of  menstruation,'  and  that  the  follicle  may 
remain  unruptured  for  a  considerable  time  after  it  is  mature,  the  escape 
of  the  ovule  being  subsequently  determined  by  some  accidental  cause, 
such  as  sexual  excitement.  However  this  may  be,  there  is  good  reason^ 
to  believe  that  the  susceptibility  to  conception  is  greater  during  the  ' 
menstrual  epochs.  ^Raciborski  belie v^es  that  in  the  large  proportion  of 
cases  impregnation  occurs  in  the  first  half  of  the  menstrual  interN'al  or 
in  the  few  days  immediately  preceding  the  appearance  of  the  dischargey 
There  are,  however,  very  numerous  exceptions,  for  in  Jewesses,  who 
almost  invariably  live  apart  from  their  husbands  for  eight  days  after 
the  cessation  of  menstruation,  impregnation  must  constantly  occur  at 
some  other  period  of  the  interval,  and  it  is  certain  that  they  are  not  less 
prolific  than  other  people.  This  rule  with  them  is  very  strictly  adhered 
to,  as  will  be  seen  by  the  accompanying  interesting  letter  from  a  medical 
friend  who  is  a  well-known  member  of  that  community,  and  which  I 
have  permission  to  publish.^     This  fact  is  of  itself  sufficient  to  disprove 

1  10  Bernard  Street,  Kvsseli,  Square,  July  '21, 1S7:5. 

My  Dear  Sir  : 

1.  Tothebest  of  my  knowledge  and  belief,  the  law  which  prohibits  sexual  intercourse 
among  Jews  for  seven  clear  days  after  the  cessation  of  menstruation  is  almost  univer- 
sally observed  ;  the  exceptions  not  being  sufficient  to  vitiate  statistics.  The  law  has 
perhaps  fewer  exceptions  on  the  Continent — especially  Russia  and  Poland,  where  the 
Jewish  population  is  very  great — than  in  England.  Even  here,  however,  women  wlio 
observe  no  other  ceremcmial  law  observe  this,  and  cling  to  it  after  everything  else  is 


92  ORGANS  CONCERNED  IN  PARTURITION. 

the  ihcfvv  advanced  \)\  Dr.  Avrard,'  lliat  iiiipreguatioii  is  iinj)()s.sil)lt'  in 
llu'  latter  half  oC  the  ineiistrual  interval.  This  and  the  other  reasotis 
referred  to  nndonhtedly  throw  some  donbt  on  the  ovnlar  theory,  hut  they 
do  not  seem  to  be  sufficient  to  justify  tiie  eonelusion  that  menstruation  is 
a  physiological  process  altogether  independent  of  the  development  and 
maturation  of  tlie  Graafian  follicles.  All  that  they  can  be  fairly  held 
to  ])rove  is  that  the  escape  of  the  ovules  may  occur  independently  of 
menstruation,  but  the  weight  of  evidence  remains  strongly  in  fiivor 
of  the  theory  which  is  generally  received.  Jt  should  be  stated  that 
Lawson  Tait  attributes  considerable  influence  in  menstruation  to  the 
Fallopian  tubes  themselves ;  but  his  views  on  this  point,  ba.sed  on  obser- 
vations made  after  the  removal  of  the  ovaries  for  certain  morbid  con- 
ditions, cannot  yet  be  taken  as  proved;  and  Thornton'^  has  related  a 
case  in  which  he  removed  both  tubes,  leaving  the  ovaries  intact,  in 
Mhich  menstruation  subsequently  went  on  as  liefore. 

The  cause  of  the  monthly  periodicity  is  quite  unknown,  and  will 
probably  always  remain  so.     Goodman^  has  suggested  what  he  ad  Is  the 
"cvclieal  theory  of  menstruation,"  which  refei-s  the  phenomena  to  a  gen- 
eral condition  of  the  vascular  system  specially  localizing  itself  in  the 
generative  organs,  and  connected  with  rhythmical  changes  in  their  nerve- 
centres.     It  does  not  seem  to  me,  however,  that  he  has  satisfactorily 
proved  the  recurrence  of  the  conditions  which  his  ingenious  theory 
assumes.     The  purpose  of  the  loss  of  so  much  blood  is  also  somewhat 
obscure.     To  a  certain  extent  it  must  be  considered  an  accident  or  com- 
plication of  ovulation  produced  by  the  vascular  turgescence.  ( Isor  is  it 
.essential  to  fecundation,  because  women  often  conceive  during  lactation, 
'when  menstruation  is  suspended,  or  before  the  function   has   becoiue 
1  established.!    It  may,  however,  serve  the  negative  purjiose  of  relieving 
the  congested  uterine  capillaries,  Avhich  are  periodically  filled  with  a 
supply  of  ])lood  for  the  great  growth  which  takes  place  when  coucep- 

thrown  overboard.  There  are  doubtless  many  exceptions,  especially  among  the  better 
classes  in  England,  wlio  keep  only  three  days  after  the  cessation  of  the  menses. 

2.  The  law  is — as  you  state — that  should  the  discharge  last  only  an  liour  or  so,  or 
should  there  be  onlyone  gush  or  one  spot  on  the  linen,  the  five  days  during  wliich  the 
period  viif/lit  continue  are  observed  ;  to  whicli  must  be  superadded  the  seven  clear  days 
— twelve  days  per  mensem  in  which  connection  is  disallowed.  Should  any  discharge 
be  seen  in  the  intermenstrual  period,  seven  days  would  have  to  be  kept.  Iiut  not  the 
five,  for  such  irref/ular  discharge. 

3.  The  "bath  of  purification,"  which  must  contain  al  Iraitt  eighty  gallons,  is  used  on 
the  last  night  of  the  seven  clear  days.  It  is  not  used  till  after  a  bath  for  cleansing 
purposes;  and  from  the  night  Mheii  such  '' i)urifying  "  bath  is  used  .Jewish  women  are 
accustomed  to  calculate  the  commencement  of  pregnancy.  That  you  .should  not  have 
heard  it  is  not  strange:  its  mention  would  be  considereil  liighly  indelicate. 

4.  .Jewish  women  reckon  their  pregnancy  to  last  nine  calendar  or  ten  lunar  months 
— 270  to  280  davs.  There  are  no  special  data  on  which  to  reckon  aii  average,  nor  do 
1  know  of  anv  books  on  the  subject,  excej)!  some  Tahuudic  authorities,  which  1  \yill 
look  up  for  you  if  you  desire  it.  Pray  make  no  apologies  for  writing  to  me  :  any  infor- 
mation I  possess  is  at  your  service. 

I  am,  dear  sir,  vours  very  truly. 
Dr.  Plavfair.  "  A.  Asher. 

p.j^._Tlie  biblical  foundation  for  the  law  of  the  seven  clear  days  is  Leviticus  xv. 
verse  19  till  the  end  of  the  chapter — especially  verse  28. 

1  Rrr.de  Therap.  Med.-Chir.,  1867. 

»   Oh.«tef.  Trans.,  1886,  vol.  xxviii.  p.  41. 

^  American  Journal  of  Obstetrics,  1878,  vol.  xi.  ]>.  073. 


OVULATION  AND  MENSTRUATION.  93 

tion  has  occurred.  Thus  immediately  before  each  period  the  uterus 
may  be  cousidered  to  be  placed  by  the  afflux  of  Ijlood  iu  a  state  of 
preparation  for  the  fuuctiou  it  may  be  suddenly  called  upon  to  per- 
form. That  the  discharge  relieves  a  state  of  vascular  tension  which 
accompanies  ovulation  is  proved  by  the  singular  phenomenon  of  vicari- 
ous menstruation  which  is  occasionally,  though  rarely,  met  with.  It 
occurs  in  cases  in  which,  from  some  unexplained  cause,  the  discharge 
does  not  escape  from  the  uterine  mucous  membrane.  Under  such  cir- 
cumstances a  more  or  less  regular  escape  of  blood  may  take  place  from 
other  sites.  The  most  common  situations  are  the  mucous  membranes  of 
the  stomach,  of  the  nasal  cavities,  or  of  the  lungs ;  the  skin,  not  un- 
commonly that  of  the  mammte,  probably  on  account  of  their  intimate 
sympathetic  relation  with  the  uterine  organs ;  from  the  surface  of  an 
ulcer ;  or  from  hemorrhoids.  It  is  a  noteworthy  fact  that  in  all  these 
cases  the  discharge  occurs  in  situations  where  its  external  escape  can 
readily  take  place.  This  strange  deviation  of  the  menstrual  discharge 
mav  be  taken  as  a  sign  of  general  ill-health,  and  it  is  usually  met  with 
in  delicate  young  women  of  highly  mobile  nervous  constitution.  It 
mav,  however,  begin  at  puberty,  and  it  has  even  been  observed  during 
the  whole  sexual  life.  The  recurrence  is  regular,  and  always  iu  connec- 
tion with  the  menstrual  nisus,  although  the  amount  of  blood  lost  is  much 
less  than  in  ordinary  menstruation. 

Cessation  of  Menstruation. — After  a  certain  time  changes  occur, 
showing  that  the  woman  is  no  longer  fitted  for  reproduction ;  roeiistru- 
ation  ceases,  Graafian  follicles  are  no  longer  matured,  and  the  ovaryJ)&;- 
comes  shrivelled  and  wrinkled  on  its  surface.  Analogous  alterations 
take  place  in  the  uterus  and  its  appendages.  The  Fallopian  tubes  atro- 
phy, and  are  not  unfrequently  obliterated.  The  uterus  decreases  in  size. 
The  cervix  undergoes  a  remarkable  change,  which  is  readily  detected  on 
vaginal  examination ;  the  projection  of  the  cervix  into  the  vaginal 
canal  disappears,  and  the  orifice  of  the  os  uteri  in  old  women  is 
foimd  to  be  flush  with  the  roof  of  the  vagina.  In  a  large  number 
of  cases  there  is,  after  the  cessation  of  menstruation,  an  occlusion  l^oth 
of  the  external  and  internal  os ;  the  canal  of  the  cervix  between  them, 
however,  remains  patulous,  and  is  not  unfrequently  distended  with  a 
mucous  secretion. 

The  age  at  which  menstruation  ceases  varies  much  in  different  women. 
In  certain  cases  it  may  cease  at  an  unusually  early  age,  as  between  thirty 
and  forty  years,  or  it  may  continue  far  beyond  the  average  time,  even  np 
to  sixty  years;  and  exceptional,  though  perhaps  hardly  reliable,  instances 
are  recorded  iu  which  it  has  continued  even  to  eighty  or  ninety  years. 
These  are,  however,  strange  anomalies,  which,  like  cases  of  unusually 
])recocious  menstruation,  cannot  be  considered  as  having  any  bearing  on 
the  general  rule.  Most  cases  of  so-called  protracted  menstruation  will 
be  found  to  be  really  morbid  losses  of  blood  depending  on  malignant  or 
other  forms  of  organic  disease,  the  existence  of  M^hich,  under  such  cir- 
cumstances, should  always  be  suspected. 

In  this  country  menstruation  usually  ceases  between  forty  and  fifty 
years  of  age.  Raciborski  says  that  the  largest  number  of  cases  of  cessa- 
tion are  met  with  iu  the  foi^-sixth  year.     It  is  generally  said  that 


94  ORGANS  CONCERNED  IN  PARTURITION. 

woiiu'ii  \\ln»  coiiiinciKv  t(»  iiR'nstniate  when  xcvy  ycjung  cease  to  do  so 
at  a  comparatively  early  age,  .so  that  the  average  duration  of  the  fime- 
tion  is  al)out  the  same  in  all  women,  C'azeaux  and  JiacihorsUi,  whose 
opinion  is  strengthened  by  the  observations  of  (Jny  in  1500  cases/ 
think,  on  the  contrary,  that  the  earlier  menstruation  commences  the 
longer  it  lasts,  early  mensturation  indicating  an  excpss  of  vital  energy 
-which  continues  during  the  whole  childbearing  life.  (Climate  and  other 
accidental  causes  d^^  n()t  seem  to  have  as  much  effect  on  the  cessation  as 
oil  tiie  estal)lishment  of  the  functioii^  It  docs  not  api)ear  to  cease 
earlier  in  warm  than  in  temperate  climates.  The  change  of  life  is 
generally  indicated  by  irregularities  in  the  recurrence  of  the  discharge. 
It  seldom  ceases  suddenly,  but  it  may  be  absent  for  one  or  more  periods, 
and  then  occur  irregularly;  or  it  may  become  profuse  or  scanty  until 
eventually  it  entirely  stops.  The  popidar  notions  as  to  the  extreme 
danger  of'  the  meno})ause  are  probably  much  exaggerated,  although  it 
is  certain  that  at  that  time  various  nervous  phenomena  are  apt  to  be 
developed.  So  far  from  having  a  prejudicial  effect  on  the  health,  how- 
ever, it  is  not  an  uncommon  observation  to  see  an  hysterical  woman, 
who  has  been  for  years  a  martyr  to  uterine  and  other  complaints,  appar- 
ently take  a  new  lease  of  life  when  her  uterine  functions  have  ceased 
to  be  in  active  operation  ;  and  statistical  tables  aljundantiy  prove  that  the 
general  mortality  of  the  sex  is  not  greater  at  this  than  at  any  other 
time. 


^       cX 


'  3Ied.  Times  and  Gaz.,  1845. 


^iVf 


PART   II. 

PREGNANCY. 


CHAPTER  I. 

CONCEPTION  AND  GENEEATION. 

Generation  in  the  human  female,  as  in  all  mammals,  requires 
the  congress  of  the  two  sexes,  in  order  that  the  semen,  the  male  ele- 
ment of  generation,  may  be  brought  into  contact  with  the  ovule,  the 
female  element  of  generation. 

The  semen  secreted  by  the  testicle  of  an  adult  male  is  a  viscid,  opal- 
escent fluid,  forming  an  emulsion  when  mixed  with  water,  and  having 
a  peculiar  faint  odor,  which  is  attributed  to  the  secretions  which  are 
mixed  with  it,  such  as  those  from  the  prostate  and  Cowper's  glands. 
On  analysis  it  is  found  to  be  an  albuminous  fluid,  holding  in  solution 
various  salts,  principally  phosphates  and  chlorides,  and  an  animal  sub- 
stance, sperraatin,  analogous  to  fibrin.  Examined  under  a  magnify- 
ing power  of  from  400  to  500  diameters,  it  consists  of  a  transparent  and 
homogeneous  fluid,  in  which  are  floating  a  certain  number  of  granules 
and  epithelial  cells  derived  from  the  secretions  mixed  with  it,  and^cer- 
tain  characteristic  bodies,  the  spermatozoa,  which  are  developed  •  from 
the  sperm-cells,  and  which  form  its  essential  constituents.  The  sperm- 
cells  are  those  occupying  the  tubuli  seminiferi  of  the  testicle.  Several 
kinds  of  sperm-cells  are  described  which  receive  their  name  from  the 
position  they  occupy  with  regard  to  the  lumen  of  the  tubule  (Fig.  4-4). 
The  cells  which  are  next  to  the  wall  of  the  tubule  are  called  the  outer 
or  lining  cells.  They  are  more  or  less  flattened  in  form,  and  are  situa- 
ted on  a  distinct  ])asement  membrane.  Internal  to  this  layer  is  another, 
consisting  of  round  cells,  the  nuclei  of  which  are  in  a  state  of  prolifera- 
tion :  this  is  the  intermediate  layer.  Between  this  and  the  lumen  of  the 
tubule  are  a  number  of  cells  irregular  in  shape,  amongst  which  are  im- 
bedded the  heads  of  the  spermatozoa,  the  tails  of  which  project  into  the 
lumen.  The  spermatozoa  are  tliought  to  arise  from  the  middle  or  ]>ro- 
liferating  layer  in  the  following  manner:  the  nuclei  of  the  sperm-cells 
proliferate,  and  from  their  subdivisions  arise  the  heads  of  the  sperma- 
tozoa, the  bodies  of  which  originate  from  the  protoplasm  of  the  cells. 
By  the  decomposition  of  the  substance  in  which  the  heads  of  the  sperm- 
atozoa are  imbedded  the  contained  spermatozoa  become  liberated  and 
move  about  freely  in  the  seminal  fluid.     As  seen  under  the  microscope, 

95 


96  PREGNANCY. 

the  spermatozoa,  whirh  exist  in  healthy  semen  in  cnonnDii-  numbers, 
present  the  a])])t'anince  ot"  minute  jiaitieles  not  unlike  a  tadpole  in 
shape.  The  head  is  oval  and  flattened,  measuring  about  Ywk^()  "^^  ^" 
inch  in  breadth,  and  attaehed  to  it  i)y  a  short  intermediate  j)ortion  is  a 
delicate  lilamentt)us  exjiansion  or  tail,  Avhieh  tapers  to  a  point  so  fine 
that  its  termination  cannot  be  seen  by  the  highest  powers  of  the  micro- 
sec  »pe.  The  whole  spermatozoon  measures  from  ^^  to  -^^  of  an 
iucli    in    length.      The  spermatozoa    are    observed   to  be   in   constant 

Fig.  Ai. 


^■'-■''^■.:.    : ;-■ 

'^''^r 

^  ■' ' 

c 

Section  of  Parts  of  Three  Seminiferous  Tubules  of  the  Rat. 

a.  With  the  spermatozoa  least  advancedin  deTC'loiimeiit.  h.  More  advanced,  c.  Coiitaininp  fully-developed 
spermatozoa.  Between  the  tubules  are  eeeii  strands  of  interstitial  cells  and  lymph-spaces.  (From  a 
preparation  by  Mr.  A.  Frazer.) 

motion,  sometimes  very  rapid,  sometimes  more  gentle,  which  is  suji- 
posed  to  be  the  means  by  which  they  pass  ujnvard  through  the  female 
genital  organs.  They  retain  their  vitality  and  power  of  movement  for 
a  considerable  time  after  emission,  provided  the  semen  is  kept  at  a  tem- 
perature similar  to  that  of  the  body.  Under  such  circumstances  they 
have  been  observed  in  active  motion  from  forty-eight  to  seventy-two 
hours  after  ejaculation,  and  they  have  also  been  .seen  alive  in  the  testicle 
as  long  as  twenty-four  hours  after  death.  In  all  j)robability  they  con- 
tinue active  much  longer  within  the  generative  organs,  as  many  physi- 
ologists have  observal  them  in  full  vitality  in  bitches  and  rabbits  seven 
or  eight  days  after  copulation.  (The  recent  experiments  of  Haussman, 
however,  show  that  they  lose  their  power  of  motion  in  the  human 
vagina  within  twelve  hours  after  coitus,  although  they  doubtle.'^s  re- 
tain it  longer  in  the  uterus  and  Fallopian  tubes.\  Abundant  leucorrheal 
tlischarges  and  acrid  vaginal  secretions  destroy  their  movements,  and 
may  thus  cause  sterility  in  the  female.  On  account  of  their  mobility, 
the  spermatozoa  were  long  considered  to  be  independent  animalcule^ — a 
view  which  is  by  no  means  exploded,  and  has  been  maintained  in  mod- 
ern times  by  Pouchet,  Joulin,  and  other  writers,  while  Coste,  Robin, 


CONCEPTION  AND   GENERATION.  97 

Kolliker,  etc.  liken  their  motion  to  that  of  ciliated  epithelium.  There 
can  be  uo  doubt  that  the  i'ertilizing  power  of  the  semen  is  due  to  the 
presence  of  the  s])ermato/oa,  althou<>;h  some  of  the  older  physiologists 
assigned  it  to  the  spermatic  fluid.  The  former  view,  however,  has  been 
conclusively  proved  by  the  experiments  of  Provost  and  Dumas,  who 
found  that  on  carefully  removing  the  spermatozoa  by  filtration  the 
semen  lost  its  fecundating  properties. 

Sites  of  Impregnation. — There  has  been  great  difference  of  opinion 
as  to  the  i)art  of  the  genital  tract  in  which  the  spermatozoa  and  the  ovule 
ct)me  into  contact,  and  in  which  impregnation,  therefore,  occurs.  Sperm- 
atozoa have  been  observed  in  all  parts  of  the  female  genital  organs  in 
animals  killed  shortly  after  coitus,  especially  in  the  Fallopian  tubes,  and 
even  on  the  surftice  of  the  ovary.  The  phenomena  of  ovarian  gesta- 
tion, and  the  fact  that  fecundation  has  been  proved  to  occur  in  certain 
animals  within  the  ovary,  tend  to  support  the  idea  that  it  may  also  occur 
in  the  human  female  before  the  rupture  of  the  Graafian  follicle.  In 
order  to  do  so,  however,  it  is  necessary  for  the  spermatozoa  to  penetrate 
the  proper  structure  of  the  follicle  and  the  epithelial  covering  of  the 
ovary ;  and  no  one  has  actually  seen  them  doing  so.  vMost  probably  the  ! 
contact  of  the  spermatozoa  and  the  ovule  occurs  very  shortly  after  the 
rupture  of  the  follicle  and  in  the  outer  part  of  the  Fallopian  tubes^) 
Coste  maintains  that  unless  the  ovule  is  impregnated  it  very  rapidly 
degenerates  after  being  expelled  from  the  ovary,  partly  by  inherent 
changes  in  the  ovule  itself,  and  partly  because  it  then  soon  becomes 
invested  by  an  albuminous  covering  which  is  impermeable  to  the 
spermatozoa.  He  believes,  therefore,  that  impregnation  can  only 
occur  either  on  the  surface  of  the  ovary  or  just  within  the  fimbri- 
ated extremity  of  the  tube.  . 

Mode  in  "which  the  Ascent  of  the  Semen  is  Effected. — The 
semen  is  probably  carried  upward  chiefly  by  the  inherent  mobility  of 
the  spermatozoa.  It  is  believed  by  some  that  this  is  assisted  by  other 
agencies  :  amongst  them  are  mentioned  the  peristaltic  action  of  the 
uterus  and  Fallopian  tubes  ;  a  sort  of  capillary  attraction  effected  when 
the  walls  of  the  uterus  are  in  close  contact^  similar  to  the  movement  of 
fluid  in  minute  tubes  ;  and  also  the  vibratile  action  of  the  cilia  of  the 
epithelium  of  the  uterine  mucous  membrane.  The  action  of  the  latter  is 
extremely  doubtful,  for  they  are  also  supposed  to  effect  the  descent  of 
the  ovule,  and  they  can  hardly  act  in  two  opposite  ways.  The  move- 
ment of  the  cilia  being  from  within  outward,  it  would  certainly  oppose 
rather  than  favor  the  progress  of  the  spermatozoa.  |(It  must,  therefore,, 
be  admitted  that  they  ascend  chiefly  through  their  own  powers  of 
motion.j  They  certainly  have  this  power  to  a  remarkable  extent,  for 
there  are  numerous  cases  on  record  in  which  impregnation  has  occurred 
without  penetration,  and  even  when  the  hymen  was  quite  entire,  and  in 
■which  the  semen  has  simply  been  deposited  on  the  exterior  of  the 
vulva :  in  such  cases,  which  are  far  from  uncommon,  the  sjiermatozoa 
must  have  found  their  way  through  the  whole  length  of  the  vagina. 
^It  is  probable,  however,  that  under  ordinary  circumstances  the  passage 
of  the  spermatic  fluid  into  the  uterus  is  facilitated  by  changes  which 
take  place  in  the  cervix  during  the  sexual  orgasm,  in  the  course  of 
7 


98 


rRECNAyCY. 


Fig.  45. 


wliicli  the  OS  uteri  is  said  to  dilate  and  dose  ap;aiii   in  a   rliytliiuical 

manner.' 

ImpregTiation. — The    precise    method    in   which    the    spermatozoa 

etlecl  inipi'ejinati(»ii  was  lonir  a  matter  of  doiiht.     Jt   is  now,  however, 

(crtain   tliat  they  actually  ])enetrate  the  ovule  and  readi  its  interior. 

This    has    been    couclusively    proved    hy  the    observations   of  Barry, 

Meissner,  and   others/ who    have    seen    the 

spermatozoa  within  the  external  membrane 

of  the  ovule  in  rabbit.4(Fig.  45).     In  some 

of  the  invertebrata  a  canal  or  openinj^  exi.sts 

in   the    yjma  pellucida  through  which    the 

sjiCiMuatozoa    ])ass.     No   such    aperture    has 

yet    been    demonstrated  in    the    ovules   of 

manunals,    but    its    existence    is    far    from 

imjM'obable.     According  to  the  ob.sers'ations 

of   Newport,  several  spermatozoa  penetrate 

the  zona  j)cllucida  and  enter  the  ovule  ;  and 

the  greater  the  number  that  do  so  the  more 

,„^^.  .  .  certain  fecundation  becomes.     In  the  lower 

0\Tim  of  Rabbit  containing  •        i       i       c     •  /■     i  •  i 

Spermatozoa.  animals  the  iusion  ot  tlie  spermatozoa  Avith 

1.  Zona  peiiucuia.   2.  The  germs, con-  the  substaucc  of  the  vclk  has  bccu  obscrvcd : 

sisting    of  two   large  cells,   several  ii,i  i-m'i  i  ■ 

smaller  cells,  and  spermatozoa.         aud  although  Similar  phenomena  have  not 

been  observed  in  the  human  ovum,  there  is 
not  any  doubt  but  tliat  the  further  development  of  the  ovum  is  due  to 
the  union  of  the  spermatozoon  with  the  female  element. 

Tlie  length  of  time  which  lapses  before  the  fecundated  ovule  ari'ives 
in  the  cavity  of  the  uterus  has  not  yet  been  ascertained,  and  it  pi'obably 
varies  under  different  circumstances.  It  is  known  that  in  the  bitch  it 
may  remain  eight  or  ten  days  in  the  Fallopian  tulie,  in  the  guinea-pig 
three  or  four.  In  the  human  female  the  ovum  has  never  been  discov- 
,ered  in  the  cavity  of  the  uterus  before  the  tenth  or  twdi'th  day 
'after  impregnation. 

The  changes  which  occur  in  the  human  ovule  immediately  before  and 
after  impregnation,  and  during  its  progress  through  the  Fallopian  tube, 
are  only  known  to  us  by  analogy,  as,  of  course,  it  is  impossible  to  study 
them  by  actual  observation.  We  are  in  possession,  however,  of  accu- 
rate information  of  what  has  l)een  made  out  in  the  lower  animals,  and 
it  is  reasonable  to  suppose  that  similar  changes  occur  in  man.  Imme- 
diately after  the  ovule  has  passed  into  the  Fallopian  tube  it  is  found  to 
be  surrounded  by  a  layer  of  granular  cells,  a  portion  of  the  lining 
membrane  <i|"  the  (n-aaliaii  loliicic,  which  was  described  as  the  discus 
proligerus.  As  it  proceeds  along  the  tul)e  these  surrounding  cellsMXb- 
apjicar,  ])artly,  it  is  supposed,  by  friction  on  the  walls  of  the  tube,  and 
partly  l)v  being  absorbed  to  nourish  the  ovule.  Be  this  as  it  may, 
before  long  tliey  are  no  longer  ob.served,  and  the  zona  jiellucida  toi^ns 
the  oiiteniuot  l;iy(  r  of  the  ovule.  When  the  ovule  lias  advanced  some 
distance  along  the  tube,  it  becomes  invested  with  a  covering  of  albumi- 
nous  material,  which  is  deposited  around  it  in  successive  layers,  the 
thickness  of  which  varies  in  different  animals.     It  is  very  abundant  in 

*  How  do  the  Spermatozoa  Enter  the  Uterm  ?     By  J.  Beck,  M.  D. 


CONCEPTION  AND   GENERATION  99 

birds,  in  whom  It  forms  the  familiar  wliite  of  the  egg.     In  some  ani- 
mals it  lias  not  l)een  detected,  so  that  its  presence  in  the  hiimun  ovule 
is  uncertain.     Where  it  exists  it  doubtless  contributes  to  the  nourish- 
ment of  the  ovule.     Coincident  with  tJiese  changes  is  the  disappeai- 
ancc  of  the  gcrniinal  vesicle.     At  the  same  time  the  yelk  contract  and 
becomes  more  solid,  retiring  from  close  contact  with   the  zona  pellu- 
cida,  and  thus  leaving  a  space   between 
the  outer  edge  of  the  yelk  and  the  vitel- 
line membrane,  which  in  some  animals  is 
filled  with  a  transparent  li(|uid.     Coinci- 
dent with  the  shrinking  of  the  yelk,  a 
small  granular  mass  of  a  rounded  form 
is  extruded  from  the  yelk  into  the  clear 
space  beneath  the  zona  pellucida.     At  a 
later  period  another  similar  mass  is  extru- 
ded.    These  are  the  polar  globules  (Fig.  > 
46),  and  it  is  thought  from  observations            ^%  j^ 
on  the  iuvertebrata  that  they  arise  from                      =  w^:..^-    - 
the    germinal   vesicle,    the    remains   of     Formation  of  the  "  Poiar  Giobuie." 

which      give     origin     to      a     new     nucleus,    l.  zona     pellucida,    containing     sperma- 

which  is  known  as  the  female  pronucleus.  Se.  ^■5.\'ile"poL''giobuie^'''^'"'°^' 
Those     changes    occur    in     all     ovules, 

whether  they  are  impregnated  or  not,  but  if  the  ovule  is  not  fecundated 
no  further  alterations  occur.  Supposing  impregnation  has  taken  place 
by  the  entrance  of  a  spermatozoon  within  the  zona  pellucida  of  the 
ovule,  a  second  nucleus  is  formed  by  the  penetration  of  the  spermato- 
zoon within  the  yelk,  where  it  loses  its  tail  and  becomes  transformed 
into  a  granular  body,  the  male  pronucleus.  After  a  time  the  male  and 
female  pronuclei  approach  one  another,  and  finally  fuse  to  form  a  nss' 
nucleus,  and  the  ovum  then  receives  the  name  of  the  blastosphere.  or 
first  segmentation-sphere.  After  this  occurs  the  very  peculiar  phenom- 
enon known  as  the  cleavage  of  the  yelk,  which  results  in  the  formation 
of  the  layer  of  cells  from  which  the  foetus  is  developed.  The  segmen- 
tation of  the  yelk  (Fig.  47)  occupies  in  mammals  the  whole  of  its  sub- 
stance. In  birds  the  cleavage  is  confined  to  a  small  area  of  the  yelk 
called  the  cicatricula  or  blastoderm.  Hence  the  term  holoblastic  has 
been  applied  to  the  ova  of  mammals,  meroblastic  to  those  of  birds.  It 
divides  at  first  into  two  halves,  and  at  the  same  time  the  new  or  first 
segmentation-nucleus  becomes  constricted  in  its  centre,  and  separates 
into  two  ])ortions,  one  of  Avhich  forms  a  centre  for  each  of  the  halves 
into  which  the  yelk  has  divided.  Each  of  these  immediately  divides 
into  two,  as  does  its  contained  portion  of  the  nucleus,  and  so  on  in  rapid 
succession  until  the  whole  yelk  is  divided  into  a  number  of  divisions, 
each  of  which  consists  of  a  clump  of  nucleated  protoplasm. 

By  these  continuous  dichotomous  divisions  the  whole  yelk  is  formed 
into  a  granular  mass,  which,  from  its  supposed  resemblance  to  a  mul- 
berry, has  been  named  the  iiMnj'qrmbody.  AVhen  the  subdivision  of 
the  yelk  is  completed  its  separate  parts  become  converted  into  a  number 
of  cells,  each  of  which  consists  of  a  mass  of  granular  protoplasm. 
These  cells  unite  by  their  edges  to  form  a  continuous  lining  (Fig.  48), 


100 


PREGNANCY. 


which,  through  the  expansion  of  the  piprifnrm  hmly  hy  fluid  \vhjrh 
forms  in  its  interior,  is  rl intended  until  it  forms  a  lining  to  the  zona  pcl- 
hu'ida.  'J  lii>  is  tlie  bhixtoihrinU-  lacinbrdiic.  fntin  wliich  the  ibutus  is 
developed,  iiy  this  time  the  ovum  has  reached  the  uterus  ;  and  heiore 
proceeding  to  consider  the  further  changes  which  it  undergoes  it  will 

F'lo.  47. 


ect 


Sections  of  the  Ovum  of  the  Rabbit  during  the  Later  Stages  of  Segmentation,  showing  the 
formation  of  the  blastodermic  vesicle.    (After  E.  v.  Benedcu.) 

a.  Section  showing  the  enclosure  of  entomeres,  eii/.,  by  ectomeres,  ect.,  except  at  oue  spot— tne  blastopore. 
h.  More  advanced  stage,  in  which  fluid  is  beginning  to  accumulate  between  the  entomeres  and 
ectomeres,  the  former  completely  enclosed,  c.  The  fluid  has  much  increased,  so  that  a  large  space 
separates  entomeres  from  ectomeres,  excei)t  at  one  part  </.  blastodermic  vesicle,  its  wall  formiHl 
of  a  layer  of  ectodermic  cells,  with  a  patch  of  entomeres  adhering  to  it  at  one  part.  2.^.,  ect.,  enl.  As 
before. 


be  well  to  study  the  alteration  which  the  stimulus  of  impregnation  has 
set  on  foot  in  the  mucous  membrane  of  the  uterus  in  order  to  prepare  it 
for  the  reception  and  growth  of  its  contents. 

Even  before  the  ovum  reaches  the  uterus  the  mucous  membrane 
becomes  thickened  and  vascular,  so  that  its  o})posing  surfaces  entirely 
fill  the  uterine  cavity.  Tliese  changes  may  be  said  to  be  the  same  in 
kind,  although  more  marked  and  extensive  in  degree,  as  the  alterations 
which  take  ])lace  in  the  nuicous  membrane  in  connection  with  each 
menstrual  period.  The  result  is  the  formation  of  a  distinct  membrane, 
which  affords  the  ovum  a  safe  anchorage  and  jjmtection  until  its  con- 
nections with  the  uterus  are  more  fully  developed.  After  delivery  this 
membrane,  which  is  by  that  time  quite  altered  in  aj>])carance,  is  at  least 


CONCEPTION  AND   GENERATION.  101 

partially  thrown  off  with  the  ovum  ;  on  which  account  it  has  received 
the  name  of  the  decldua  caduca. 

The  decidua  consists  of  two  principal  portions,  which  in  early  preg- 
nancy are  separated  from  each  other  by  a  considerable  interspace,  which 
is  occupied  by  mucus.  One  of  these,  called  tiie  decidua  vera,  lines 
the  entire  uterine  cavity,  and  is,  no  doubt,  the  original  mucous  lining 
of  the  uterus  greatly  hypertrophied.  The  second,  the  decidua  r^flexa. 
is  closely  applied  round  the  ovum,  and  it  is  proljably  formed  "by  the 
sprouting  of  the  decidua  vera  around  the  ovum  at  the  point  on  which 
the  latter  rests,  so  that  it  eventually  completely  surrounds  it.  As  the 
ovum  enlarges  the  decidua  refiexa  is  necessarily  stretched  until  it  comes 
everywhere  in  contact  with   the   decidua  vera,  with  which   it  firmly 

Fig.  48. 


Formation  of  the   Blastodermic   Membrane   from  the  Cells  of  the   Muriform  Body.     (After 

Joulin.) 

1.   Layer  of  albuminous  material  surrounding  2.   The  zona  pell  ucida. 

unites.  After  the  third  month  of  pregnancy  true  union  has  occurred, 
and  the  two  layers  of  decidua  are  no  longer  separate.  I  The  decidua  ser- 
otina,  which  is  described  as  a  third  portion,  is  merely  that  part  of  the 
decidua  vera  on  which  the  ovum  rests,  and  where  the  placenta  is  event- 
ually developed^  it  is  characterized  by  its  extreme  vascularity,  which 
serves  the  purpose  of  supplying  nutriment  to  the  fwtus  through  the 
capillaries  of  the  foetal  placenta. 

It  is  needless  to  refer  to  the  various  views  w^hich  have  been  held  by 
anatomists  as  to  the  structure  and  formation  of  the  decidua.  That 
taught  by  John  Hunter  was  long  believed  to  be  correct,  and  down  to  a 
recent  date  it  received  the  adherence  of  most  physiologists.  He  believed 
the  decidua  to  be  an  inflammatory  exudation  which,  on  account  of  the 
stimulus  of  pregnancy,  was  thrown  out  all  over  the  cavity  of  the  uterus, 
and  soon  formed  a  distinct  lining  membrane  to  it.  AMien  the  ovum 
reached  the  uterine  orifice  of  the  Fallopian  tube  it  found  its  entrance 
barred  by  this  new  membrane,  which  accordingly  it  pushed  before  it. 


102 


PREGNANCY. 


This  separated  portion  formed  a  covcriii;;  to  tlio  ovmii,  and  l)ecame  the 
dec'idiia  roHcxa,  wliih-a  fresh  cxiidatioii  tddk  place  at  that  portion  of  the 
uterine  wall  wliicli  wa.s  thus  laid  bare,  and  this  became  the  decidua  ser- 
otina.  William  Hunter  had  much  more  correct  views  of  the  deeidna, 
the  accuracy  of  which  was  at  the  time  much  contested,  but  which  have 
recently  received  full  recognition,  ^lle  describes  the  decidua  in  his 
earlier  writings  as  an  li^pertropliy  of  the  uterine  inucous  membrane 
itself — a  view  which  is  now  held  by  all  jjliysiologists.) 

"N^'hen  the  decidua  is  lirst  formed  it  is  a  hollow  triangular  sac  lining 
the  uterine  cavity  (Fig.  49),  and  liaviug  three  openings  into  it — tho.se 


Fig.  49. 


Aborted  0\-um  of  about  Forty  Days,  showing  the  triangular  shape  of  the  decidua  (which  is 
laid  open),  and  the  aperture  of  the  Fallopian  tube.    (After  Coste) 

of  the  Fallopian  tubes  at  its  ujiper  angles,  and  one,  corresponding  to 
the  internal  os  uteri,  below.  If,  as  is  generally  the  case,  it  is  thick  and 
pulpy,  these  openings  are  closed  up  and  can  no  longer  be  detected.  In 
earlv  pregnancy  it  is  well  developed,  and  continues  to  grow  up  tojthe 
third  month  of  utero-gestation.  After  that  time  it  commences  to 
atroi)hy,  its  adhesion  with  the  uterine  walls  lessens,  it  becomes  thin  and 
transparent,  and  is  ready  for  expulsion  when  delivery  is  etfected. 
AVhen  it  is  most  developed  a  careful  examination  of  the  decidua 
enables  us  to  detect  in  it  all  the  elements  of  the  uterine  mucous  mem- 
brane greatly  hypertro])hied.  Its  substance  chiefly  consists  of  large 
round  or  oval  nucleated  cells  and  elongated  fibres,  mixed  with  the 
tubular  uterine  glands,  which  are  much  elongated,  lined  V)y  columnar 
ciliated  epithelial  cells,  and  contain  a  small  quantity  of  milky  fluid. 
According  to  Friedliinder,  the  decidau  is  divisible  into  two  layers  :  the 
inner  being  formed  by  a  proliferation  of  the  corpuscles  of  the  subepi- 


CONCEPTION  AND   GENERATION. 


103 


thelial  connective  tissue  of  the  mucous  membrane ;  the  deeper,  in  con- 
tact witli  the  uterine  walls,  out  of  flattened  or  compressed  gland-ducts. 
In  an  early  abortion  the  extremities  of  these  duets  may  be  observed  by 
a  lens  on  the  external  or  uterine  surface  of  the  decidua,  occupying  the 
summit  of  minute  projections  separated  from  each  other  by  depressions. 
If  these  projections  be  bisected,  they  will  be  found  to  contain  little 
cavities  filled  with  lactescent  fluid,  Avhich  were  first  described  by  Mont- 
gomery of  Dublin,  and  are  known  as  J\Io)itr/omery's  cups.  They  are 
in  fact  the  dilated  canals  of  the  uterine  tubular  glands.  On  the  inter- 
nal surface  of  such  an  early  decidua  a  number  of  shallow  depressions 
may  be  made  out,  which  are  the  open  mouths  of  these  ducts. 

The  decidua  vera  is  highly  vascular,  and  its  vascularity  persists  till 
after  the  seventh  month  of  pregnancy;  the  decidua  reflexa  is  only  vas- 
cular during  the  early  part  of  pregnancy,  depending  for  its  vascularity 
chiefly  on  the  villi  of  the  chorion,  and  hence  losing  this  with  their 
atrophy. 

When  the  ovum  reaches  the  uterine  cavity  it  soon  becomes  imbedded 

in  the  folds  of   tiie  hypertrophied   mucous    membrane,  which  almost 

entirely  fills   the  uterine   cavity.     As  a   rule,  it    is  attached  to  some 

point   near    the    opening  of  a    Fallopian  tube,  the  swollen  folds  of 

raucous  membrane    preventing    its   descent   to  the  lower  part  of  the 

uterus;    in   exceptional    circumstances,  however — as    in   women  who 

have  borne  many  children  and  have  a  more  than  usually  dilated  uterine 

cavity — it  may  fix  itself  at  a  point  much  nearer  the  internal  os  uteri. 

I  According  to  the  now  generally  accepted  opinion  of  Coste,  the  mucous 

i  membrane  at  the  base  of  the  ovum  soon  begins  to  sprout  around  it, 

■  and  gradually  extends  until  it  eventually  covers  the  ovum  (Figs.  50- 

52),  and  forms  the  decidua  reflexa.     Coste  describes,  under  the  name 


Fig.  50. 


Fig.  51. 


Fig.  52. 


Formation  of  Decidua. 

(Tlie  decidua  is  colored 
lilack  ;  the  ovum  is  rep- 
resented as  engagod  be- 
tween two  projecting  folds 
of  membrane.) 


Projectiiiff  Folds  of  Mem- 
brane growing  up  around 
the  Ovum. 


Showing  Ovum  completely 
surrounded  by  the  Decidua 
Reflexa. 


of  the  umbilicus,  a  small  depression  at  the  most  prominent  part  of  the 
ovum,  which  he  considers  to  be  the  indication  of  the  point  where 
the  closure  of  the  decidua  reflexa  is  eftected.     There  are  some  objections 


104 


PREGNANCY. 


to  this  theory,  for  no  one  lias  seen  the  decidua  reflexa  incomplete  and 
in  the  process  of  formation  ;  and  on  examining  its  external  surface — 
that  is,  the  one  farthest  from  the  ovum — its  microscopical  a])pearance 
is  identical  \vitli  that  of  the  inner  surface  of  the  decidua  vera.  To 
meet  these  tiiHicultics,  Weber  and  (joodsir,  whose  views  have  been 
adopted  by  Priestley,  contended  that  the  decidua  rcHcxa  is  "  the  ])ri- 
marv  lamina  of  the  mucous  membrane,  which,  when  the  ovum  enters 
the  uterus,  separates  in  two-thirds  of  its  extent  from  the  layei-s  beneath 
it  to  adhere  to  the  ovum  ;  the  rcmainin<i:  third  remains  attached  and 
forms  a  centre  of  nutrition."  According  to  this  view,  the  decidua 
vera  would  be  a  subsequent  growth  over  the  se])aratc(l  portion,  and 
the  decidua  serotina  the  portion  of  the  primary  lamina  which  remained 
attached.  In  this  way  the  fact  of  the  opposed  surfaces  of  the  decidua 
vera  and  reflexa  being  identical  in  structure  would  be  accounted  for. 
The  difficulty  which  this  theory  is  intended  to  meet  does  not  seem  so 
great  as  is  supposed,  for  if,  as  is  likely,  it  is  only  the  epithelial  or 
internal  surface  of  the  mucous  membrane  which  sprouts  over  the 
ovum,  and  not  its  deeper  layers,  the  facts  of  the  case  would  be  suf- 
ficiently met  by  Coste's  view. 

/(Up  to  the  third  m.Qulli  of  pregnancy  the  decidua  reflexa  and  vera  are 
nW  in  close  contact,  and  there  may  even  be  a  considerable  interspace 
between  them,  which  sometimes  contains  a  small  quantity  of  mucous 
fluid  called  the  Itydropcrionc.  \\  This  fact  may  account  for  the  curious 
circumstance — of  which  many  instances  are  on  record — that  a  uterine 
sound  may  be  passed  into  a  gravid  uterus  in  the  early  months  of  preg- 
nancv  without  necessarily  producing  abortion,  and  also  for  the  occasional 
occurrence  of  menstruation  after  conception  (Figs.  53  and  81).     Evcutu- 


FiG.  53. 


An  Ovum  removed  from  Uterus,  and  Part  of  the  Decidua  Vera  cut  away.    (After  Coste.) 

a.  Decidua  vera,  showing  the  follicles  opening  on  its  inner  surface,     h.  Inner  extremity  of  Fallopian  tube. 

c.  Flap  of  decidua  reflexa.     d.  Ovum. 

ally,  by  the  growth  of  the  ovum,  the  decidua  reflexa  comes  closely  into 
contact  with  the  vera,  and  the  two  become  intimately  blended  and 


CONCEPTION  AND  GENERATION.  105 

inseparable.  The  inner  surface  of  tlie  dceidua  reflexa  blends  with  tlie 
outer  surface  of  the  chorion,  so  that  at  birth  the  decidua  vera,  the  decidua 
reflexa,  and  the  chorion  are  re])resented  by  one  membrane. 

As  pregnancy  advances  the  decidua  alters  in  appearance  and  becomes, 
fibrous  and  thin.  In  the  later  months  of  utero-gestation  fatty  degenera- 
tion of  its  structure  commences,  its  vessels  and  glands  are  obliterated,  j 
and  its  adhesion  to  the  uterine  -walls  is  lessened,  so  as  to  prepare  it  for' 
separation.  As  we  shall  subsequently  see,  this  fatty  degeneration  was! 
assumed  by  Simpson  to  be  the  determining  cause  of  labor  at  term.| 
After  the  eighth  month  thrombi  form  in  the  veins  lying  underneath) 
the  decidua  serotina,  and  at  the  end  of  pregnancy  they  are  described  by  | 
Leopold^  as  having  become,  to  a  great  extent,  obliterated.  This,  he  I 
supposes,  may  have  some  effect  in  inducing  the  contractions  of  the' 
uterus  in  labor. 

It  was'  long  believed  that  the  entire  decidua  was  thrown  off  after 
labor,  leaving  the  muscular  coat  of  the  uterus  bare  and  denuded,  and 
that  a  new  raucous  membrane  was  formed  during  convalescence. 
According  to  Robiu,^  whose  views  are  corroborated  by  Priestley,  no  such 
denudation  of  the  muscular  tissue  of  the  uterus  ever  occurs,  but  a  por- 
tion of  the  decidua  always  remains  attached  after  delivery.  :  After  the 
fourth  month  of  pregnancy  they  believe  that  a  new  mucous  membrane 
is  formed  under  the  decidua,  which  remains  in  a  somewhat  imperfect 
condition  till  after  delivery,  when  it  rapidly  develops  and  assumes  the 
proper  functions  of  the  mucous  lining  of  the  uterus!  Robin  also 
believes  that  that  portion  of  the  decidua  which  covers  the  placental  site, 
the  so-called  decidua  serotina,  is  not  thrown  off  with  the  membranes, 
like  the  decidua  vera  and  reflexa,  but  remains  attached  to  the  uterine 
walls,  a  thin  layer  of  it  only  being  expelled  with  the  placenta,  on  which 
it  may  be  observed.  Duncan  ^  entirely  dissents  from  these  view^s,  and 
does  not  admit  the  formation  of  a  new  mucous  membrane  during  the 
later  months  of  utero-gestation.  He  believes  that  the  greater  portion 
of  the  decidua  is  thrown  off,  but  that  part  remains,  and  from  this  the 
fresh  mucous  membrane  is  developed.  This  view  is  similar  to  that  of 
Spiegelberg,  who  holds  that  the  portion  of  the  decidua  that  is  expelled 
is  the  more  superficial  of  the  two  layers  described  by  Friedliinder,  com- 
posed chiefly  of  the  epithelial  elements,  while  the  deeper  or  glandular 
layer  remains  attached  to  the  walls  of  the  uterus.  From  the  epithelium 
of  the  glands  a  new  epithelial  layer  is  rapidly  developed  after  delivery. 
Leopold*  has  shown  that  the  uterine  mucous  membrane  is  completely 
re-formed  within  six  weeks  after  delivery,  and  that  its  regeneration  is 
sometimes  completed  as  early  as  the  end  of  the  third  week.  This  theory 
bears  on  the  well-known  analogy  of  the  uterus  after  delivery  to  the 
stump  of  an  amputated  limb — an  old  simile  principally  based  on  the 
erroneous  theory  that  the  whole  muscular  tissue  of  the  uterus  was  laid 
bare.     This,  as  w-e  have  seen,  is  not  the  case,  but  the  simile  so  far  holds 

^  Arch.f.  Oyn.,  1887,  Bd.  xi.  Hft.  3,  S.  443  :  "  Studien  uber  die  Uterus-schleimhaut 
wiihrend  Menstruation." 

^  Memoircsde  I' Acad.  Imp.  de  Med.,  1861. 

^  Researcheii  in  ObMdria^,  p.  186  et  neq. 

*  Arch.f.  Gyn.,  1877,  Bd.  xii.  Hft.  2,  S.  169. 


106 


PREGNANCY. 


good  in  that  the  mucous  lining  is  tloprived  of  its  epithelial  covering; 
and  this  fact,  together  with  the  existence  of  numerous  oi)en  veins  on  the 
interior  of  the  uterus,  readily  exj)lains  the  extreme  susce])tibility  to 
septic  absorption  \vhicli  forms  so  j)eculiar  a  characteristic  of  the  puer- 
peral state. 

licfore  we  commenced  the  study  of  the  decidua  we  had  trace*!  the 
impregnated  ovum  into  the  uterine  cavity,  and  described  the  formation 
of  the  blastodermic  membrane  by  the  junction  of  the  cells  of  the  muri- 
form  bodv.  We  nuist  now  proceed  to  consider  the  further  changes 
which  residt  in  the  devcloi)ment  of  the  fretus  and  of  the  membranes 
that  surround  it.  It  would  be  quite  out  of  place  in  a  work  of  this 
kind  to  enter  into  the  subject  of  embryology  at  any  length,  and  we  must 
therefore  be  content  with  such  details  as  are  of  importance  from  a 
practical  point  of  view. 

The  blastodermic  membrane,  which  forms  a  complete  spherical 
lining  to  the  ovum  between  the  yelk  and  the  zona  pellucida,  soon 
divides  into  two  layers,  of  which  the  external  is  called  the  cpihhi.st,  the 
internal  the  hypohlad,  and  between  these  is  subsecjuently  developed  a 
third  laver,  known  as  the  mcHohlaat.  From  these  three  layers  are 
formed  the  entire  foetus  :  theejjiblast  giving  origin  to  the  central  ner- 
vous system,  to  the  suiierficiaT  layer  of  the  skin,  and  aiding  in  formation 
of  the  organs  of  special  sense  and  of  the  amnion  ;  the,hv])obIast  forming 
the  epithelial  lining  membrane  of  the  alimentary  and  rcs])ii-at»iry  tracts 
and  of  the  tubes  and  glands  in  connection  with  them,  and  hel[)ing  in  the 
development  of  the  yelk-sac ;  the  mesoblast  giving  rise  to  the  skeleton, 
the  niiiscles,  the  connective  tissues,  the  vascular  system,  the  genito-uri- 
nary  organs,  and  taking  part  in  the  formation  of  all  the  membranes. 

Almost  inmiediately  after  the  separation  of  the  blastodermic  mem- 
brane into  layers  one  part  of  it  becomes  thickened  by  the  aggregation 
of  cells,  and  is  called  the  area  germinativa.     This  is  at  first  round  and 

then  oval  in  shape,  and  at  its 
margin  the  first  indication  of  the 
embryo  may  be  detected  in  the 
form  of  a  narrow  thickening,  the 
prhnitkc  trace.  This  becomes  elon- 
gated and  stretches  in  a  stra])-like 
form  along  the  centre  of  the 
germinal  area ;  it  is  considered  by 
Balfour  to  represent  the  blastojwro 
of  animals,  the  ova  of  which 
undergo  invagination  to  form  a 
gastrula.  Surrounding  it  are  some 
cells  more  translucent  than  those 
of  the  rest  of  the  area  germinativa, 
and  hence  called  the  area  peUurijla 
(Fig.  54).  In  front  of  the  primi- 
tive trace  two  elevated  ridges  soon 
arise,  the  lamince  dorsales,  which  include  between  them  a  groove,  the 
medullary  groove,  and  gradually  unite  jiosteriorly  to  form  a  cavity 
within  which  the  cerebro-spinal  axis  is  subsequently  developed.     The 


Fig.  54. 


Diagram  of  Area   Oerminativa,  showing  the 
primitive  trace  unci  area  pellucida. 


CONCEPTION  AND   GENERATION. 


107 


Fig.  55. 


medullary  groove  as  it  grows  backward  overlaps  the  primitive  trace, 
which  disappears.  The  embryo  is  differentiated  from  the  rest  of  the 
blastoderm  by  a  fold  anteriorly,  which  is  culled  the  cephalic  or  head- 
fold.  Another  fold  afterward  a])i)cars  posteriorly,  which  is  called  tlie 
caudal  or  tail-fokh  Laterally,  folds  also  arise.  These  folds  all  tend  to 
grow  toward  the  centre  of  the  under  surface  of  what  will  be  the 
embryo. 

The  mesoblastic  layer  of  the  blastoderm,  except  that  part  which  forms 
the  axis  of  the  embryo,  splits  into  an  upper  layer,  the  somatopleure, 
which  is  beneath  the  epiblasr,  and  a  lower  layer,  the  splanchnopleure, 
which  lies  upon  the  hypoblast.  The  space  formed  by  this  cleavage  of 
the  raesoblast  is  called  the  pleuro-peritoneal  cavity.  The  somatopleure 
is  engaged  in  the  formation  of  the  body-walls  of  the  embryo.  The 
splanchnopleure  forms  the  walls  of  the  alimentary  tract. 

Formation  of  the  Aranion. — Processes  arise  from  the  somatopleure 
anteriorly,  posteriorly,  and  laterally,  which  gradually  arch  over  the 
dorsal  surface  of  the  foetus,  until 
they  meet  each  other  and  form  a 
complete  envelope  to  it.  At  the 
ventral  surface  these  processes  are 
separated  by  the  whole  length  of 
the  embryo,  but  they  here  also  gradu- 
ally approach  each  other,  and  eventu- 
ally surround  what  is  subsequently 
the  umbilical  cord,  and  blend  with 
the  integument  of  the  foetus  at  the 
point  of  its  insertion.  In^tliis  way 
is  formed  the  amnion  (Fig.  55),  con- 
sisting of  two  layers  :  the  internal, 
derived  from  the  epjblast,  is  formed 
of  tessellated  epithelial  cells ;  the 
external,  arising  from  the  mesoblast, 
is  formed  of  cells  like  those  of  young 
connective  tissue.  Before  the  folds 
of  the  amnion  unite  the  free  edge  of 

each  is  bent  outward  and  spread  around  the  ovum  immediatelv  within 
the  zona  pellucida,  forming  a  lining  to  it,  termed  by  Turner  the  snbzonal 
membrane,  which  is  connected  with  the  development  of  the  chorion. 
In  man  this  reflected  layer,  or  false  amnion,  consists  only  of  epiblast, 
but  in  some  other  animals  it  is  probably  formed  from  both  the  meso- 
blast and  the  epiblast,  like  the  true  amnion.  The  amnion  is  the  most 
internal  of  the  membranes  surrounding  the  foetus,  and  will  presently  be 
studied  more  in  detail.  It  soon  becomes  distended  with  fluid,  the  liquor 
amnii,  ajidas  this  increases  in  amount  it  separates  the  amnion  more  and 
more  from  the  foetus. 

During  this  time  the  innermost  layer  of  the  blastodermic  membrane 
or  hypoblast  is  also  developing  two  projections  at  either  extremity  of  the 
foetus,  and  these  gradually  approach  each  other  anteriorly.  As  the  hypo- 
blast is  in  contact  with  the  yelk,  when  these  meet  they  have  the  eifect  of 
dividing  the  yelk  into  two  portions.     One,  and  the  smaller  of  the  two. 


7-^Lr-\_rxS''{-' 


Development  of  the  Amnion. 
Vitelline  membrane.  2.  Externul  layer  of 
blastodermic  membrane.  3.  Internal  layers 
forming  the  umbilical  vesicle.  4.  Umbilical 
vessels.  5.  Projections  forming  amnions. 
6.  Embryo.     7.  Allantois. 


108 


PREGNANCY. 


forms  eventually  the  intestinal  eanal  of  the  fnotns;  the  other,  and  niu<h 
the  larger,  contains  the  greater  portion  of  the  yelk,  and  forms  the  cjihcni- 
eral  strnetnre  known  as  the  luithi/lrd/  vcsir/c,  from  which  the  fo'tus 
ilerives  most  of  its  noni-ishmcnt  (hiring  the  early  stage  of  its  existence, 
its  eomnuun'cation  with  tiic  aUlominal  cavity  of  the  foetus  is  through 
the  constricted  portion  at  the  point  of  division  called  the  vitelline  dud 
(Fig.  5G).  An  artery  and  vein,  the  oiiijjhalo-incnejitcric,  ramify  on  the 
vesicle  and  its  duct. 

Fig,  56. 


Fig.  57. 


1.  Eso-chorion.      2.  External  layer  of  blastodermic  membrane.     3.  Umbilical  vesicle.     4.  Its  veseele. 
5.  Amnion.     6.  Embrjo.     7.  AUiiutois  increasing  in  size. 

As  the  amnion  increases  in  size  it  pushes  back  the  umbilical  vesicle 

toward  the  external  membrane  of  the  ovum,  between  which  and  the 

amnion  it  lies  (Fig.  o7) ;  and  when  the  allantois  is 

developed  it  ceases  to  be  of  any  use,  and  rajiidly 

shrinks  and  dwindles  away.     In   most  mammals 

no  trace  of  it  can  be  found  after  the  fourth  month  , 

of  utero-gestation  ;l  in  some,  including  the  human 

female,  it  is  said  to  exist  as  a  minute  vesicle  at  the  | 

placental   end  of  the   umbilical   cord   at  the   full  ( 

period    of   pregnancy.)    The   umbilical   vesicle   is 

iilled    with    a    yellowish    tluid,   containing   many 

oil  and    fat-globules,  similar    to    the   yelk  of  an 

The  Allantois. — Somewhere  about  the  twen- 
tieth day  after  eoneeptioii  a  small  vesicle  is 
formed  toward  the  caudal  extremity  of  the  f(etus, 
which  is  called  the  (tlUoitois.  This  membrane  in 
mammals  is  important,  as  it  fmins  the  gicater  jiart 
of  the  fptal  placenta,  a  small  ptn-tioii  of  it  remain- 
iiiLi'  in-ide  the  body  ])ermaiiently  as  the  bladtler.  It 
begins  as  a  divertieulum  from  the  lower  ])art  of  the  intestinal  canal, 
and  is  hence  formed  externally  by  the  s])lanehn()])leural  layer  of  the 
mesoblast,  whilst  internally  it  is  lined  by  the  hypoblast.  It  is  at  first 
spherical,  but  it  rapidly  develops  and  becomes  })yriibrm  in  shape,  wiiile 


An  Embryo"  of  about 
twenty-five  days  laid 
open.     (After  Coste.) 

a.  Chorion,     b.  Amnion, 
c.  Cavity  of  chorion, 
rf.  I'lnliilical  ve.side. 
e.   I'ediclo  of  allantois. 
/.  Embryo. 


CONCEPTION  AND  GENERATION. 


109 


by  a  process  of  constriction  similar  to  that  which  occurs  in  tlie  vitcllus 
to  form  the  umbilical  vesicle  it  becomes  divided  into  two  parts,  coni- 
rauuicating  with  each  other,  the  smaller  of  them  being  eventually 
develoj)ed  into  the  urinary  bladder.  The  larger  portion,  leaving  the 
abdominal  cavity  along  with  the  vitelline  duct,  rapidly  grows  until  it 
comes  into  contact  with  the  most  external  ovular  membrane,  the  chorion. 


Fig.  58. 


1.  Exo-chorion.     2.  External  layer  of  the  blastodermic  membrane.     3.  Allantois.     4.  Umbilical  yeside. 
5.  Amnion.     6.  Embryo.     7.  Pedicle  of  allantois. 

over  the  inner  surface  of  which  it  spreads.  This  part  consists  chiefly  of 
mesoblastic  tissue,  the  hypoblast  only  passing  to  the  end  of  the  stalk  of 
the  allantois,  and  not  following  the  mesoblast  as  it  spreads  over  the 
inner  surface  of  the  chorion.  The  area  of  the  chorion  over  which  the 
allantois  spreads  varies  in  different  animals: {in  man  it  spreads  over  the 
entire  surface,!but  in  the  rabbit  it  only  occupies  one-third  of  the  chorion, 
the  remaining  two-thirds  being  occupied  by  the  yelk-sac.  This  varying 
distribution  of  the  allantois  helps  to  differentiate  the  placentation  of  man 
and  the  apes  from  that  of  rodents.  In  the  mesoblastic  tissue  of  thej 
allantois  vessels  soon  develop — namely,  the  two  umbilical  arteries,! 
derived  from  the  abdominal  aorta,  and  two  umbilical  veins^  one  of  j 
which  subsequently  disappears;  these,  along  with  the  vitelline  duct  and) 
the  pedicle  of  the  allantois,  form  the  umbilical  cord.  The  main  and 
very  important  function  of  the  allantois,  therefore,  is  to  carry  the  foetal 
ves.sels  up  to  the  inner  surface  of  the  subzonal  membrane.  Besides 
this  purpose,  the  allantois  at  a  very  early  period  may  receive  the  excre- 
tions of  the  foetus  and  serve  as  an  excrementitious  organ.  Accordina: 
to  Cazeaux,  scarcely  a  trace  of  the  allantois  can  be  seen  a  few  days  after 
its  formation.  Its  lower  part  or  pedicle,  however,  long  remains  dis- 
tinct, and  forms  part  of  the  umbilical  cord;  and  traces  of  it  may  be 
found  even  in  adult  life  in  the  form  of  the  urachus,  which  is  really  the 
dwindled  pedicle  and  forms  one  of  the  ligaments  of  the  bladder.  The 
cavity  of  the  allantois  in  the  human  species  is  confined  chiefly  to  that 
part  which  lies  within  the  body  of  the  foetus;  it  is  seldom  persistent 
farther  than  the  stalk  of  the  allantois. 


110  rJiEGXAyCY. 

Bi'twoc'ii  the  cliorion  aiiil  ainnion  is  often  ioniid  an  alhiiiiiinous  fluid, 
with  minute  Jilanicntous  ])roccsse.s  traversing  it,  called  Ity  \'el|K'au  the 
corpf<  ndicidc,  which  is  not  met  with  until  the  allantois  comes  into  con- 
tact with  the  chorion,  and  which  seems  to  he  formed  out  of  the  tissues 
of  that  vesicle.  It  is  analogous  to  the  so-called  \\'harton's  jelly  found 
in  the  umbilical  cord.  AVhen  first  foi-med  it  is  highly  vascular,  hut  the 
vessels  entirely  disappear  after  the  ])lacenta  is  formed,  and  the  remain- 
der of  the  choi'ionic  villi  atroj)liy.  Sometimes  it  exists  in  considerable 
quantities,  and,  shoidd  the  chorion  rupture  at  the  end  of  pregnancy  it 
may  escape  and  give  rise  to  an  erroneous  impression  that  the  liquor 
amuii  has  been  discharged  (Fig.  59). 

Before  proceeding  to  consider  the  fVctal  envelopes  more  at  length,  it 
may  be  useful  to  reca})itulate  the  structures  already  alluded  to  as  form- 
ing the  ovum.     In  this  we  find — 

1.  The  cmbrijo  itself. 

2.  A  fluid,  the  liquor  amnii,  in  wdiich  it  floats. 

3.  The  amnion,  a  purely  foetal  membrane  surrounding  the  embiyo 
and  containing  the  liquor  amnii. 

4.  The  umbilical  vesicle,  containing  the  greater  portion  of  the  yelk, 
serving  as  a  source  of  nuti'ition  to  the  early  embiyo  through  the 
vitelline  duct,  and  on  which  ramify  the    omphalo-mcsenteric  vessels. 

5.  The  allantois,  a  vesicle  proceeding  from  the  caudal  extremity  of 
the  embiyo,  spreading  itself  over  the  interior  of  the  ovum,  and  serving 
as  a  channel  of  vascular  communication  between  the  chorion  and  the 
fcetus  through  the  umbilical  vessels. 

6.  An  interspace  Ijctween  the  outer  layer  of  the  ovum  and  tlie 
amnion,  in  w'hich  is  contained  the  umbilical  vesicle  and  allantois  and 
the  corps  recticule  of  Velpean. 

7.  The  outer  layer  of  the  ovum,  along  M'ith  the  subzonal  membrane, 
forming  the  chorion  and  foetal  placenta. 

The  ainnion  is  the  most  internal  of  the  two  membranes  surrounding 
the  fietus;  its  origin  at  an  early  period  of  fetal  life  has  already  been 
described.  It  is  a  perfectly  smooth,  transparent,  but  tough  membrane, 
continuous  with  the  integument  of  the  foetus  at  the  insertion  of  the 
umbilical  cord,  round  Avliich  it  forms  a  sheath.  Soon  after  it  is 
formed  it  becomes  distended  with  a  fluid,  the  liquor  amnii,  in  which 
the  foetus  is  suspended  and  floats.  This  fluid  increases  gradually  in 
quantity,  distending  the  amnion  as  it  does  so,  until  this  is  brought  into 
close  proximity  to  the  inner  surface  of  the  chorion,  from  Mhich  it  was 
at  first  separated  by  a  considerable  interspace. 

The  internal  surface  of  the  amnion  is  smooth  and  glistening,  and  on 
microscopic  examination  it  is  found  to  consist  of  a  layer  of  flattened 
cells,  each  containing  a  large  nucleus.  These  rest  on  a  stratum  of 
fibrous  tissue  which  gives  to  the  membrane  its  toughness,  and  by  which 
it  is  attached  to  a  layer  of  gelatinous  tissue  which  separates  it  from  the 
inner  surface  of  the  chorion.  This  fibrous  layer  contains  muscidar 
fibres  which  give  to  the  amnion  its  contractility.  It  is  entirely  destitute 
of  vessels,  nerves,  and  lymphatics.  The  quantity  of  the  licjuor  anuiii 
varies  nuich  at  different  periods  of  jiregnancy.  In  the  early  months  it 
is  relatively  greater  in  amount  than  the  foetus,  which  it  outweighs.     As 


CONCEPTION  AND   GENERATION. 
Fig.  59. 


111 


^nariTi^ 


Five  Diagrammatic  Figures  illustrating  the  Formation  of  the  Fcetal  Membranes  of  a  Mammal. 

(After  Kolliker.) 

In  1,  2,  3,  4,  the  embryo  is  represented  in  longitudinal  section. 

1.  Ovum  with  zona  peilucida,  blastodermic  vesicle,  and  embiyonic  area. 

2.  Ovum  witli  commencing  formation  of  umbilical  vesicle  and  amnion. 

3.  Ovum  with  amnion  about  to  cease,  and  commencing  allantois. 

4.  Ovum  with  villous  subzonal  membrane,  larger  allantois,  and  mouth  and  anus. 

5.  Ovum  in  which  the  mesoblast  of  the  allantois  has  extended  round  the  inner  surface  of  the  subzonal  mem- 

brane and  united  with  it  to  form  the  chorion.  The  cavity  of  tlie  allantois  is  aborted.  This  figure  is  a 
diagram  of  an  early  human  ovum. 
d.  zona  radiata;  (V  and  sz.  processes  of  zona;  sh.  subzonal  membrane,  outer  fold  of  amnion,  false  amnion; 
c/(.  chorion  ;  ch.z.  chorionic  villi ;  am.  amnion  ;  Us.  head-fold  of  amnion  ;  s.s.  txiil-fold  of  amnion  ;  a. 
cpiblast  of  embryo ;  a!,  epiblast  of  non-embryonic  part  of  the  blastodermic  vesicle ;  m.  embryonic 
mesoblast;  mt.  non-embryonic  mesoblast;  AJ.  area  vasculosa;  si.  sinus  terminalis ;  M.  embryonic 
hypobla.st ;  i.  non-embryonic  hypoblast ;  Wi.  cavity  of  blastodermic  vesicle,  the  greater  part  of  which 
becomes  the  cavity  of  umbilical  vesicle  ds. ;  dg.  stalk  of  umbilical  vesicle;  a\.  allantois;  e.  embryo; 
r.  space  between  chorion  and  amnion  containing  albuminous  fluid;  ni.  ventral  body-wall ;  hh.  pericardial 
cavity. 

pregnancy  advances  the  ^veight  of  the  foetus  becomes  four  or  five  times 
greater  tliau  that  of  the  liquor  amnii,  although  the  actual  quantity  of 
fluid  increases  during  the  whole  period  of  gestation.  The  amount  of 
fluid  varies  much  in  different  pregnancies.     Sometimes  there  is  compar- 


112  riiEG  NANCY. 

atively  little,  MJiile  at  others  the  quantity  is  immense,  reaching  several 
])()nn(ls  in  woiolit,  trroatly  distendinir  the  uterus,  and  thus,  it  nmv  he, 
j)rc)(luciuii-  (liilicuhv  in  ]al>()r. 

At  first  the  li(|iii(l   is  clear  and  limpid.     As  ])rcii.iijincy  advances  it 

, becomes  more  turbid  and  dense,  from  the  admixtui'c  of"  c])illiclial  debris 

J derived  from  the  cutaneous  surface  of  the  fictus.      In  some  cases,  with- 

/('  out  actual  disease,  it  may  be  dark  green  in  color  and  thick  and  tenacious 

/ 1  in  consistency.     It  has  a  peculiar  heavy  odor,  and  it  consists  chemically 

of  Avater  containing  albumen,  some  urea,  and  various  salts,  jn-incipally 

phosphates  and  chlorides. 

The  source  of  the  lifpior  amnii  has  been  much  disputed.  Some 
maintain  that  it  is  derived  chietiy  from  the  fcetus — a  view  sufficiently 
disproved  by  the  fact  that  the  liquor  amnii  continues  to  increase  in 
amount  after  the  death  of  the  fojtus,  Burdach  believed  that  it  is 
secreted  by  the  internal  surface  of  the  uterus,  and  an-ivcs  in  the  cavity 
of  the  amnion  l)v  transudation  through  the  meml)rane.  VPriestlev — and 
this  seems  the  most  proi)able  hypothesis — thiid<s  that  it  is  secreted  by  i 
the  epithelial  cells  lining  the  membrane,  Avhich  become  distended  Avitli 
fluid,  burst,  and  pour  their  contents  into  the  amniotic  cavity.)  Gusserow, 
whose  view  is  adopted  by  Spiegelberg,  maintains  that  in  the  latter 
months  of  pregnancy  the  quantity  of  the  liquor  amnii  is  largely  in- 
creased bv  the  foetal  urine  which  is  passed  into  the  amniotic  sac.     (See 

jy  i\  ,  The  most  obvious  use  of  the  licjuor  amnii  is  to  afford  a  fluid  medium 
|v  v*^^'^  Avhich  the  foetus  floats,  and  so  is  protected  from  the  shocks  and  jars 
'  -^^  to  which  it  would  otherwise  be  subjected,  and  from  undue  pressure  upon 
the  uterine  walls.  By  distending  the  uterus  it  saves  it  from  injuiy, 
which  the  movements  of  the  foetus  might  otherwise  inflict,  and  the 
fcetus  is  thus  also  enabled  to  change  its  position  freely.  The  facility 
with  Avhich  version  by  external  manipulation  can  be  eflected  de]>ends 
entirely  on  the  mobility  of  the  foetus  in  the  fluid  which  surrounds  it. 
Some  have  also  supposed  that  it  prevents  the  foetus  in  the  early  montlis 
of  pregnancy  from  forming  adhesions  to  the  amnion.  In  labor  it  is  of 
great  service  by  luljricating  the  passages,  but  chiefly  by  forming,  with 
the  membranes,  a  fluid  wedge  which  dilates  the  circle  of  the  os 
uteri. 

In  a  few  rare  cases  there  is  a  certain  amount  of  limjnd  fluid  be- 
tween the  chorion  and  the  amnion,  separating  the  two  membranes. 
This  is  apparently  only  a  more  than  usually  fluid  condition  of  the  gelat- 
inous tissue  which  naturally  exists  between  the  chorion  and  amnion. 
Occasionally,  after  the  bag  of  membranes  is  felt  in  lal)or  the  chorion 
alone  ruj)tures,  and  the  sjnirious  liquor  amnii  is  discharged,  giving  the 
attendant  the  impression  that  the  membranes  have  been  ruptured. 

The  chorion  is  the  more  external  of  the  truly  foetal  membranes, 
althoug-h  external  to  it  is  the  decidua,  having  a  strictlv  maternal  orisrin. 
It  is  a  perfectly  closed  sac,  its  external  surface,  in  contact  with  the 
decidua,  l)cing  rough  and  shaggy  from  the  development  of  villi  (Fig. 
56),  its  internal  smooth  and  shining.  As  the  ovum  ))asses  along  the 
Fallopian  tube  it  receives,  as  we  have  seen,  an  albuminous  coating,  and 
tbisj  with  the  zona  pellucida,  is  developed  into  a  temporary  structure,  the 


conceptioj^  and  generation.  113 

primifirc  chorion.  This  primitive  chorion  as  tho  aiiuiion  devolops  is 
reinlorccd  by  the  hiycr  of  cpihlast  coveriniL;'  tlu;  umbilical  vcsick;  cx- 
tenially,  which  separates  it  from  the  subjacent  mesoblast  and  hypoblast, 
and,  together  with  the  epiblastic  layer  of  the  false  amnion,  with  which 
it  is  coutiuuGUS,  passes  to  the  primitive  chorion,  either  combining  with 
this  or  by  ])ressure  causing  its  absorption  and  disappearance. 

The  membrane  thus  Jbrnied  is  called  by  Turner  the  subzonal  mem- 
brane, and  by  Von  Baer  the  aerouH  cnrc/ope.  From  it  are  developed 
villi  of  cellular  structure,  which  at  first  extend  as  a  ring  round  the 
ovum,  but  eventually  cover  the  whole  of  its  surface.  These  villi 
are  finger-like  projections  from  the  surface  of  the  ovum  which  are  re- 
ceived into  corresponding  depressions  iu  the  decidua,  with  which 
they  soon  become  so  firmly  united  that  they  cannot  be  separated  with- 
out laceration. 

As  the  allantois  develops,  its  mesoblastic  layer  grows  into  the  space 
between  the  embryo  and  subzonal  membrane,  and  in  the  human  subject 
spreads  over  the  whole  of  its  inner  surface,  combining  with  it  to  form 
a  new  membrane,  the  true  or  complete  chorion.  Each  villus  now 
receives  a  separate  artery  and  vein,  the  former  having  a  branch  to  each 
of  the  subdivisions  into  which  the  villus  divides.  These  vessels  are 
encased  in  a  fine  connective-tissue  sheath  from  the  allantois,  which  enters 
the  villus  along  with  them  and  forms  a  lining  to  it,  described  by 
some  as  the  endochorion,  the  external  epithelial  membrane  of  the  villus, 
derived  from  the  epiblast  layer  of  the  blastodermic  membrane,  being 
called  the  exochorion.  The  artery  and  vein  lie  side  by  side  in  the 
centre  of  the  villus,  and  anastomose  at  its  extremity,  each  villus  thus 
having  a  separate  circulation. 

As  soon  as  th.e  union  of  the  allantois  with  the  chorion  has  been 
effected  the  villi  grow  very  rapidly,  give  off  branches,  which,  in  their 
turn,  give  off  secondary  branches,  and  so  form  root-like  processes  of 
great  complexity.  In  the  early  months  of  gestation  they  exist  equally 
over  the  whole  surface  of  the  ovum.  As  pregnancy  advances,  however, 
those  which  are  in  contact  with  the  decidua  reflexa  shrivel  up,  and  by 
the  end  of  the  second  month  cease  to  be  vascular,  being  no  longer 
required  for  the  nutrition  of  the  ovum.  The  chorion  and  decidua  thus 
come  into  close  contact,  being  united  together  by  fibrous  shreds,  which 
on  microscopic  examination  are  found  to  consist  of  atrophied  villi.  The 
union  between  the  chorion  and  the  decidua  reflexa  as  pregnancy 
advances  becomes  so  complete  that  their  line  of  junction  cannot  be 
ascertained,  and  they  together  with  the  decidua  vera  form  one  mem- 
brane, which  on  its  inner  surface  is  only  separated  from  the  anniion, 
which  has  spread  over  it,  by  a  fine  layer  of  gelatinous  tissue.  The 
portion  of  the  chorion  which  is  in  relationship  to  the  decidua  reflexa 
is  known  as  the  chorion  keve,  whilst  that  in  contact  with  the  decidua 
serotina  receives  the  name  of  the  chorion  frondosura;  and  in  this 
portion  the  villi,  instead  of  dwindling  away,  increase  greatly  in  size, 
and  eventually  develop  into  the  organ  by  which  the  foetus  is  nourished 
— the  placenta. 

Form  of  the  Placenta. — This  important  organ  serves  the  pur- 
pose of  supplying  nutriment  to,  and  aerating  the  blood  of,  the  foetus, 


Ill  PREGNANCY. 

ami  (III  its  integrity  the  existence  of  tiie  foetus  (le[K'n(ls.  It  is  met 
Mitli  in  all  niaminals,  l)ut  is  very  different  in  form  and  arrangement 
in  dilli'rent  classes.  Tims,  in  the  sow,  mare,  and  in  tlie  eetaeea  it  is 
diHused  over  tiie  whole  intei-ior  of  the  uterus  ;  in  the  rmninants  it 
is  divided  into  a  number  of  sej)arate  small  masses,  .scattered  here 
and  there  over  the  entire  uterine  walls  ;  while  in  the  carnivora  and 
elephant  it  i'orms  a  zone  or  belt  round  the  uterine  cavity,  (in  the 
Junnan  race,  as  well  as  in  rodentia,  iusectivora,  etc.,  the  j)]acenta  is  ill 
the  form  of  a  circular  mass,  attached  generally  to  s(»me  part  of  i\\^ 
uterus  near  the  orifices  of  one  ]''alloj)ian  tube  ;  but  it  may  Ije  sit-j 
uated  anvMhere  in  the  uterine  (avity,  even  over  the  internal  os  uteril 
The  form  of  placentation  in  man  and  the  apes  is  known  as  the  meta- 
discoidal,  whilst  in  rodentia  and  insectivora  the  placentation  is  discoidal. 
The  metadiscoidal  placentation  is  placed  ventrally  with  regard  to  the 
eml)ryo,  and  the  allantois  extends  over  the  whole  ol"  the  subzonal  mem- 
brane, whilst  in  the  discoidal  variety  the  placenta  is  placed  dorsally, 
and  the  allantois  only  extends  over  a  jiortiou  of  the  subzonal  mem- 
brane, to  the  remainder  of  which  the  yelk-sac  is  ajiplied.  As  it  is 
expelled  after  delivery  with  the  foetal  membranes  attached  to  it,  and 
as  the  aperture  in  these  corresponds  to  the  os  uteri,  we  can  generally 
determine  pretty  accurately  the  situation  in  which  the  ])lacenta  was 
placed  by  examining  them  after  expulsion.  The  maternal  surface  of 
the  placenta  is  somewhat  convex',  the  foetal  concave.  Its  size  varies 
greatly  in  different  cases,  and  it  is  usually  largest  when  the  child  is 
big,  but  not  necessarily  so.  Its  average  diameter  is  from  6  to  8 
inches,  its  weight  from  18  to  24  ounces,  but  in  exceptional  cases  it 
has  been  found  to  weigh  several  pounds.  Abnormalities  of  form  are 
not  very  rare.  Thus,  the  placenta  has  been  found  to  be  divided  into 
distinct  parts,  a  form  said  by  Professor  Turner  to  be  normal  in  cer- 
tain genera  of  monkeys,  or  smaller  supplementary  placentae  (placentce 
siiccenttiria)  may  exist  round  a  central  mass.  These  variations  of  shape 
are  only  of  imjiortance  in  consequence  of  a  risk  of  j^art  of  the  detached 
placenta  being  left  in  the  uterus  after  delivery  and  giving  rise  to  sej)- 
tictemia  or  secondary  hemorrhage. 

The  foetal  membranes  cover  the  whole  foetal  surface  of  the  ]>la- 
centa,  being  refiet-ted  from  its  edges  so  as  to  line  the  uterine  cavity, 
and  being  expelled  with  it  after  delivery.  They  also  leave  it  at  the 
insertion  of  the  cord,  to  which  they  form  a  sheath.  The  cord  is  gen- 
erally attached  near  the  centre  of  the  placenta,  and  from  its  insertion 
the  umbilical  vessels  may  be  seen  dividing  and  radiating  over  the 
whole  fwtal  surface. 

The  maternal  surface  is  rough  and  divided  by  numerous  sulci, 
which  are  best  seen  if  the  placenta  is  rendered  convex,  so  as  to  resem- 
ble its  condition  when  attached  to  the  uterus.  A  careful  examination 
shows  that  a  delicate  membrane  covers  the  entire  maternal  surface, 
unites  the  sulci  together,  and  dips  down  between  them.  This  is,  in 
fact,  the  cellular  layer  of  the  do'cidua  serotina,  which  is  separated  and 
expelled  with  the  placenta,  the  deeper  layer  remaining  attached  to  the 
uterus.  Numerous  small  oj^enings  may  be  seen  on  the  surface,  which 
are  the  apertures  of  the  veins  torn  off  from  the  uterus,  as  also  those 


CONCEPTION  AND   GENERATION. 


115 


of  some  arteries,  which,  after  taking  several  sharp  turns,  open  suddenly 
into  the  substance  of  the  organ. 

As  regards  the  minute  structure  of  the  placenta,  it  is  certain  that  it 
consists  essentially  of  two  distinct  portions — one  ffietal,  consisting  of 
the  greatly  hypertrophied  chorion  villi,  with  their  contained  vessels, 
which  carry  the  fcetal  blood  so  as  to  bring  it  into  intimate  relation  witli 
the  maternal  blood,  and  thus  admit  of  the  necessary  changes  occurring 
in  it  connected  with  the  nutrition  of  the  foetus  ;  and  the  other  maternal, 
formed  out  of  the  decidua  serotina  and  the  maternal  blood-vessels. 
These  two  portions  are  in  the  human  female  so  intimately  l)lended  as  to 
form  the  single  deciduous  organ  which  is  thrown  off  after  delivery. 
These  main  facts  are  admitted  by  all,  but  considerable  differences  of 
opinion  still  exist  among  anatomists  as  to  the  precise  arrangement 
of  these  parts.  In  the  following  sketch  of  the  subject  I  shall  describe 
the  views  most  generally  entertained,  merely  briefly  indicating  the 
points  which  are  contested  by  various  authorities. 

The  foetal  portion  of  the  placenta  consists  essentially  of  the  ulti- 
mate ramifications  of  the  chorion  villi,  which  may  be  seen  on  micro- 
scopic examination  in  the  form  of  club-shaped  digitations,  which  are 
given  off  at  every  possible  angle  from  tlie   stem  of  a  parent  trunk, 


Placental  Villus,  greatly  magnified.    (After  Joulin.) 

1,  2.  Placental  vessels  formiug  termiual    loops.    3.    Chorion  tissue,   forming    external  walls   of    vilhis. 
4.  Tissue  surrounding  vessels. 


just  like  the  branches  of  a  plant.  Within  the  transparent  walls  of 
the  villi  the  capillary  tubes  of  the  contained  vessels  may  be  seen  lying 
distended  with  blood,  and  in*e.senting  an  appearance  not  unlike  loops 


116  PREGNANCY. 

of  small  intestine.  The  capillaries  are  the  terminal  ramitieations  of 
the  umbilical  arteries  and  veins,  ^vhich,  after  reaching  the  site  of  the 
placenta,  divide  and  subdivide  until  they  at  last  form  an  immense 
number  of"  minute  caj)illarv  vessels,  with  their  convexities  looking 
toward  the  maternal  portion  of  the  placenta,  each  terminal  looj)  being 
contained  in  one  of  the  digitations  of  the  chorion  villi.  Each  arte- 
rial twig  is  accompanied  by  a  corresjionding  venous  branch,  which 
unites  with  it  to  form  the  terminal  arch  or  loop  (Fig.  60).  The  fcetal 
blood  is  carried  through  these  arterial  tM'igs  to  the  villi,  where  it 
comes  into  intimate  contact  with  the  maternal  blood,  in  consequence 
of  the  anatomical  arrangenK-nts  ])rcsently  to  be  described  ;  but  tiie  two 
do  not  directly  mix,  as  the  older  physiologists  believed,  for  none  of 
the  maternal  blood  escapes  when  the  umbilical  cord  is  cut,  nor  can 
the  minutest  injections  through  the  fo'tal  vessels  be  made  to  pass  into 
the  maternal  vascular  system,  or  vice  versii.  In  addition  to  the  lo(>])ed 
terminations  of  the  umbilical  veasels,  Farre  and  Schroeder  van  der 
Kolk  have  described  another  set  of  capillary  vessels  in  connection 
with  each  villus  (Fig.  61).     This  consists  of  a  very  fine  network  cover- 

FiG.  61. 


a.  Terminal  villus  of  fcetal  tuft,  minutely  injected,    i.  Its  nucleated   non-vascular  s^heath. 

(After  Farro.) 

ing  each  villus,  and  very  different  in  appearance  from  the  convolu- 
ted vessels  Iving  in  its  interior,  which  are  the  only  ones  which  have 
been  usually  described.  Dr.  Farre  believes  that  these  ves.sels  only 
exist  in  the  early  months  of  pregnancy,  and  that  they  disappear  as 
pregnancy  advances.  Priestley  '  suggests  that  they  may  not  be  vessels 
at  all,  but  lym])hatics,  which  may  jiossibly  al)Sorb  nutrient  material 
from  the  mother's  blood  and  throw  it  into  the  foetal  vascular  system. 
The  existence  of  lymphatics  or  nerves  in  the  ])lacenta,  however,  has 
never  been  demonstrated,  and  they  are  believed  not  to  exist. 

As  generally  described,  the  maternal  portion  of  the  i)lacenta  consists 
of  large  cavities  or  of  a  single  large  cavity  which  contains  the  maternal 

'  The  Gravid  Ulent.%  p.  52. 


CONCEPTION  AND   GENERATION. 


117 


blood,  and  into  wliioh  tlie  villi  of  the  chorion  penetrate  (Fig.  62).  Into 
this  niaternal  ])art  of"  the  viscus  the  curling  arteries  of  the  uterus  pour 
their   blood,  which  is  collected  from   it  hy  the  uterine  sinuses.     The 


Fig.  62. 


Diagram  representing  a  Vertical  Section  of  the  Placenta.    (After  Dalton.) 
a,  a.  Chorion,     h,  b.  Decidua.     c,  c,  c,  c.  Orifices  of  uterine  sinuses. 

villi  of  the  chorion,  therefore,  are  suspended  in  a  sac  filled  with  mater- 
nal blood,  which  penetrates  freely  between  them,  and  with  which  they 
are  brought  into  very  intimate  contact.  Dr.  John  Keid  believed  that 
onlv  the  delicate  internal  lining  of  the  maternal  vessels  entered  the 


Fig.  63. 


Fig.  64. 


Diacrrnm  illustrating  the  Mode  in  which  a 
i'hicental  Villus  derives  a  covering  from 
the  Vascular  System  of  the  Mother. 
(After  Priestley.)" 

a.  Vilhis  having  three  terminal  digitations  pro- 
jecting into  6.  Cavity  of  the  mother's  vessel, 
c.  Dotted  lines  representing  coat  of  vessel. 


The    E.xtremity    of     a    Placental     Villus. 
(After  Good.sir.) 

a.  External  membrane  of  villus  (the  lining  mem- 
brane of  va.senlar  system  of  Weber). 
6.  Kxternal  colls  of  villus  derived  from  decidua. 
<?,  c.  Nuclei  of  ditto. 

d.  The  space  between  the   maternal    and  ftetal 

portions  of  villus. 

e.  Its  internal  membrane. 
/.  Its  internal  cells. 

g.  The  loop  of  umbilical  vessels. 


substance  of  the  placenta  to  form  the  sac  just  spoken  of.  Into  this  the 
villi  project,  pushing  before  them  the  meml)rane  forming  the  limiting 
wall  of  the  placental  sinuses,  each  of  them  in  this  May  receiving  an 


118  riiTy.yAycv. 

investment,  just  as  tlie  fini^ci-s  oC  a  hand  arc  coverecl  hv  a  jrlovc  (Fig. 

Seliroc'dcr  van  (Ut  Kolk  and  (loddsir  ( I'ig.  (J4)  were  of  ojiinion  that 
not  oidy  nvitc  the  niatrrnal  lilood-voscls  continncd  into  the  snh.-tance 
of  the  phieenta,  hnt  also  the  proeesses  of  the  deciihia  uliieh  aeeonipanied 
the  vessels  and  were  i)n)h>n<red  over  each  villus,  s(»  as  to  separate  it 
from  the  limiting  inend)rane  of  the  maternal  sinnses.  Kaeli  villns 
wonld  thus  be  covered  by  two  layci's  of  fine  tissue — one  from  the  inter- 
nal lining  mend)rane  of  the  maternal  blood-vessels,  the  other  from  the 
epithelial  cells  of  the  deeidna. 

Turner,  whose  valuable  researches  on  the  com])arative  anatomv  of  the 
placenta  have  thrown  much  light  on  its  sti'uctiur,  jxtints  out  that  the 
placentie  of  all  animals  are  formed  on  the  same  fundamental  type,'  in 
which  t\n2  J'(ct((l  port  ion  vom\6ts  of  a  smooth,  plane-surfaced  vascidar 
membrane  covered  with  pavement  epithelium,  which  is  brought  into 
contact  with  the  maternal  portion,  consisting  of  a  smooth,  ])lane-surfjiced 
vascular  mend)rane  covered  with  colunniar  epithelium.  The  fcetal 
capillaries  are  se))aratcd  from  the  maternal  capillaries  only  by  two 
opposed  layers  of  c]>ithelium.  In  various  animals  the  ])lacentje  are 
more  or  less  specialized  from  the  generalized  form,  in  some  to  a  much 
greater  extent  than  others.  In  the  human  ])laceuta  the  luaternal  vessels 
have  lost  their  normal  cylindrical  form,  and  are  dilated  into  a  system  of 
freely'  intercommunicating  placental  sinuses,  which  are,  in  fact,  mater- 
nal ca])illarics  enormously  enlarged,  with  their  walls  so  ex})anded  and 
thinned  out  that  they  cannot  l)e  recognized  as  a  distinct  layer  limiting 
the  sinus.  Each  fa-tal  chorion  villus  projectin<^  into  these  simises  is 
covered  witli  a  layer  of  cells  distinct  from  those  of  the  epithelial  layer 
of  the  villus,  and  readily  stripped  from  it.  These  are  maternal  in  their 
origin,  and  are  derived  from  the  deeidna,  which  sends  prolongations  of 
its  tissue  into  the  ]ilacenta.  These  cells,  he  believes,  form  a  secreting 
epithelium  which  scjiarates  from  the  maternal  blood  a  secretion  for  the 
nourishmeut  of  the  foetus,  which  is,  in  its  turn,  absorbeil  by  the  villi  of 
the  chorion. 

A  view  not  very  dissimilar  to  this  has  been  advanced  by  Professor 
Ercolani  of  Bologna,  who  maintains  that  the  maternal  jiortion  of  the 
])lacenta  is  a  new  formation,  strictly  glandular  and  not  vascular  in  its 
structure.  It  is  formed,  he  thinks,  by  the  submucous  connective  tissue 
of  the  deeidna  serotina,  and  it  dips  down  into  the  placenta  and  fitrms  a 
sheath  to  each  of  the  chorion  villi,  which  it  sejia rates  from  the  maternal 
blood.  This  new  glandular  structure  he  describes  as  secreting  a  fluid, 
termed  the  "uterine  milk,"  which  is  absorbed  by  the  villi  of  the 
chorion,  just  as  the  mother's  milk  is  absorbed  by  the  villi  of  the  intes- 
tines; and  it  is  with  this  fluid  alone  that  the  chorion  villi  are  in  direct 
contact.  The  sheath  thus  formed  to  each  villus  is  doubtless  analog<»us 
to  the  layer  of  cells  which  Goodsir  described  as  encasing  each  villus,  but 
is  attributed  to  a  new  structure  formed  after  conception. 

The  existence  of  the  maternal-simis  system  in  the  placenta  is 
altoy-cther  denied  bv  anatomists  of  eminence  whose  views  are  worthv  of 

'  Introduction  to  Human  Anatomy,  Part  2,  and  Journ.  of  Anat.  and  Plnixiolorpj,  1877, 
vol.  xi.  p.  33. 


CONCEPTION  AND   GENERATION.  119 

careful  consideration.  Prominent  amongst  these  is  Braxton  llieks/ 
who  has  written  an  elaborate  |)aj)er  on  the  subject.  He  liolds  that  tiiere 
is  no  evidence  to  prove  tliat  the  maternal  blood  is  ])oured  out  into  a 
cavity  in  which  the  (chorion  villi  float,  and  he  believes  that  the  curling 
arteries,  instead  of  entering  the  so-called  maternal  portion  of  the  ])la- 
centa,  terminate  in  the  decidua  serotiua.  The  hyperti-ophied  chorion 
villi  at  the  site  of  the  placenta  are  firmly  attached  to  the  decidual  sur- 
face, into  which  their  ti])s  are  imbedded.  The  line  of  junction  between 
the  decidua  reflexa  and  serotina  forms  a  circumferential  margin  tf),  and 
limits,  the  placenta.  The  arrangement  of  the  foetal  ])ortion  of  the  pla- 
centa on  this  view  is  very  similar  to  that  generally  described,  but  the 
villi  are  not  surrounded  by  maternal  blood  at  all,  and  nothing  exists 
between  them  unless  it  be  a  small  quantity  of  serous  fluid.  The  change 
in  the  fVetal  blood  is  effected  by  endosmosis,  and  Hicks  suggests  that 
the  follicles  of  the  decidua  may  secrete  a  fluid  which  is  poured  into  the 
intervillous  spaces  for  absorption  by  the  villi. 

Functions  of  the  Placenta. — It  will  thus  be  seen  that  anatomists 
of  repute  are  still  undecided  as  to  important  points  in  the  minute 
anatomy  of  the  placenta,  which  further  investigation  will  doubtless 
clear  up.  The  main  functions  of  the  organ  are,  however,  sufficiently 
clear.  During  the  entire  period  of  its  existence  it  fills  the  important 
office  of  both  stomach  and  lungs  to  the  foetus.  AVhatever  view  of  the 
arrangement  of  the  maternal  blood-vessels  be  taken,  it  is  certain  that  the 
foetal  blood  is  propelled  by  the  pulsations  of  the  foetal  heart  into  the 
numberless  villi  of  the  chorion,  where  it  is  brought  into  veiy  intimate 
relation  with  the  mother's  blood,  gives  off  its  carbonic  acid,  absorbs 
oxygen,  and  passes  back  to  the  foetus,  through  the  umbilical  vein,  in  a 
fit  state  for  circulation.  The  mode  of  respiration,  therefore,  in  the 
foetus  is  analogous  to  that  in  fishes,  the  chorion  villi  representing  the 
gills,  the  maternal  blood  the  water  in  which  they  float.  Nutrition  is 
also  effected  in  the  organ,  and  by  absorption  through  the  chorion  villi 
the  ])abulum  for  the  nourishment  of  the  foetus  is  taken  up.  It  also 
probably  serves  as  an  emunctory  for  the  products  of  excretion  in  the 
foetus.  Picard  found  that  the  blood  in  the  placenta  contained  an  appre- 
ciably larger  quantity  of  urea  than  that  in  other  parts  of  the  body,  this 
urea  probably  being  derived  from  the  foetus.  Claude  Bernard  also 
attributed  to  it  a  glycogenic  function,^  supposing  it  to  take  the  place  of 
the  f(etal  liver  until  that  organ  was  sufficiently  developed. 

Finally,  we  find  that  the  temporary  character  of  the  placenta  is  indi- 
cated by  certain  degenerative  changes  which  take  place  in  it  previous 
to  expulsion.  These  consist  chiefiy  in  the  deposit  of  calcareous  patches 
on  its  uterine  surface,  and  in  fatty  degeneration  of  the  villi  and  of  the 
decidual  layer  between  the  placenta  and  the  uterus.  If  this  degene- 
ration be  carried  to  excess,  as  is  not  unfrequently  the  case,  the  ftetus 
may  perish  from  want  of  a  sufficient  number  of  healthy  villi  through 
which  its  respiration  and  nuti'ition  may  be  effected. 

The  umbilical  cord  is  the  channel  of  communication  between  the 
fcetus  and  placenta,  being  attached  to  the  former  at  the  umbilicus,  to 
the  latter  generally  near  its  centre,  but  sometimes,  as  in  the  battledore 

'  OhsU  Trans.,  1873,  vol.  xiv.  p.  149.  '  Acad,  des  Sciences,  April,  1859. 


120  PREC  NANCY. 

])l:i('cnta,  at  its  (Hljie.  It  varies  iniicli  in  k"n<;tli,  ineasuriii<;  on  an  avor- 
iio^v  {'n>u\  1<S  to  24  indies,  hut  in  exceptional  eases  beinj;-  lound  its  long 
as  50  or  GO,  and  as  short  as  5  or  (i,  inches. 

A\'hen  fully  Ibrnied  it  consists  of  an  external  nienihranous  layer 
formed  of  the  amnion,  two  umbilical  arteries,  one  umbilical  vein,  and 
a  considerable  quantity  of  a  transparent  gelatinous  substance  surround- 
hvjc  the  vessels  called  AVharton's  Jelly,  Mhich  is  contained  in  a  fine 
network  of  fii)res,  and  is  formed  from  the  si^natopleural  layer  of  the 
mesoblast  in  the  cord.  At  an  early  period  of  pregnancy,  in  addition  to 
these  structures,  the  cord  contains  the  pedicle  of  the  umbilical  vesicle, 
with  the  om})halo-mesenteric  ve&sels  ramifying  on  it,  and  two  umbilical 
veins,  one  of  Mhich  soon  atrophies  and  disa])pears.  No  nerves  or 
lymphatics  have  been  satisfactorily  demonstrated  in  the  cord,  although 
such  have  been  described  as  existing.  The  vessels  of  the  cord  are  at 
first  straight  in  their  course,  but  shortly  they  become  greatly  twisted, 
the  arteries  being  external  to  the  vein,  and  in  nine  cases  out  of  ten  the 
twist  is  from  left  to  right.  Various  exi)lanations  have  been  given  of 
this  j)eculiarity,  none  of  them  entirely  satisfactory.  Tyler  .Smith 
attributed  it  to  the  movements  of  the  foetus  twisting  the  cord,  its 
attachment  to  the  placenta  being  a  fixed  point ;  this  would  not,  how- 
ever, account  for  the  frequency  with  which  the  spiral  turns  occur  in 
one  direction.  Mr.  John  Simpson  attributed  it  to  the  greater  pressure 
of  the  blood  through  the  right  hypogastric  artery,  on  account  of  that 
vessel  having  a  more  direct  relation  to  the  aorta  than  the  left.  The 
umbilical  arteries  give  off  no  branches,  and  the  vein  contains  no  valves, 
nor  can  any  vasa  vasorum  l)e  detected  in  their  coats  after  they  have  left 
the  uml)ilicus.  The  umbilical  arteries  increase  in  size  after  they  leave 
the  cord  to  divide  on  the  surface  of  the  placenta.  This  is  the  only  ex- 
ample in  the  body  in  which  arteries  are  larger  near  their  terminations 
than  their  origin,  and  the  object  of  this  arrangement  is  probably  to 
eifect  a  retardation  of  the  current  of  the  blood  distributed  to  the 
placenta.  The  tortuous  course  of  the  vein  probably  com])ensates  for 
the  absence  of  valves,  and  moderates  the  flow  of  blood  through  it. 
Distinct  knots  are  not  unfrequently  observed  in  the  cord,  but  they 
rarelv  have  the  effect  of  obstructing  the  circulation  through  it.  They 
no  doubt  form  when  the  fretus  is  very  small.  They  may  sometimes 
also  be  ])roduced  in  labor  by  the  child  l)eing  jM'opelled  through  a  coil 
of  the  cord  lying  circularly  round  the  os  uteri.  The  so-called  false 
knots  are  merely  accidental  nodosities  due  to  local  enlargements  of  the 
vessels. 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FOETUS.        121 


CHAPTER  II. 

THE   ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS. 

It  is  obviously  impossible  to  attempt  anything  like  a  full  account  of 
the  development  of  the  various  fcetal  structures  or  of  their  growth 
during  intra-uterine  life.  To  do  so  would  lead  us  far  beyond  the 
scope  of  this  work,  and  would  involve  a  .study  of  complex  details  only 
suitable  in  a  treatise  on  embryology.  It  is  of  importance,  however, 
that  the  practitioner  should  have  it  in  his  power  to  determine  approxi- 
mately the  age  of  the  foetus  in  abortions  or  premature  lal)ors,  and  for 
this  purpose  it  is  necessary  to  describe  briefly  the  appearance  of  the 
fcetus  at  various  stages  of  its  growth, 

1st  month. — The  foetus  in  the  first  month  of  gestation  is  a  minute 
gelatinous  and  serai-transparent  mass,  of  a  grayish  color,  in  which  no 
definite  structure  can  be  made  out  and  in  which  no  head  or  extremities 
can  be  seen.  It  is  rarely  to  be  detected  in  abortions,  being  lost  in  sur- 
rounding blood-clots.  In  the  few  examples  which  have  been  carefully 
examined  it  did  not  measure  more  than  a  liue  in  length.  It  is,  how- 
ever, already  surrounded  by  the  amnion,  and  the  pedicle  of  the  umbili- 
cal vesicle  can  be  traced  into  the  unclosed  abdominal  cavity. 

2d  month. — The  embryo  becomes  more  distinctly  apparent,  and  is 
curved  on  itself,  weighing  about  6.2  grains  and  measuring-  6  to  8 
linesjn  length.  The  head  and  extremities  are  distinctly  visible — the 
latter  in  the  form  of  rudimentary  projections  from  the  body.  The  eyes 
are  to  be  seen  as  small  black  spots  on  the  side  of  the  head.  The  spinal 
column  is  divided  into  separate  vertebriB.  The  independent  circulatory 
system  of  the  foetus  is  now  beginning  to  form,  the  heart  consisting  of 
only  one  ventricle  and  one  auricle,  from  the  former  of  which  both  the 
aorta  and  pulmonary  arteries  arise.  On  either  side  of  the  vertebral 
column,  reaching  from  the  heart  to  the  pelvis,  are  two  large  glandular 
structures,  the  corpora  Wolfjiana,  which  consist  of  a  series  of  convolu- 
ted tubes  opening  into  an  excretory  duct  running  along  their  external 
borders  and  connected  below  with  the  common  cloaca  of  the  genito- 
urinary and  digestive  tracts.  They  seem  to  act  as  secreting  glands, 
and  fulfil  the  functions  of  the  kidneys  before  they  are  formed. 
Toward  the  end  of  the  second  month  they  atrophy  and  disap- 
pear, and  the  only  trace  of  them  in  the  foetus  at  term  is  to  be 
found  in  the  parovarium  lying  between  the  folds  of  the  broad 
ligaments.  At  this  stage  of  development  there  are  met  with  in 
the  human  embryo,  as  in  that  of  all  mammals,  four  transverse 
fissures  opening  into  the  pharynx,  which  are  analogous  to  the  per- 
manent branchia?  of  fishes.  Tlieir  vascular  supply  is  also  similar,  as 
the  aorta  at  this  time  gives  off  four  branches  on  each  side,  each  of  which 
forms  a  branchial  arch,  and  these  afterward  unite  to  form  the  descend- 


122  rREGSAyX'Y. 

ing  aorta.  By  the  end  of  the  sixth  week  these,  as  well  as  the  transvei-se 
fissures  to  which  tlicy  are  (listril)Utc'(l,  disappear.  By  tlif  end  of"  the 
second  niontii  tlic  kidneys  and  suprarenal  capsules  are  torniin;^,  and  the 
single  ventricle  is  dividi-d  into  two  hy  the  growth  of  llie  interventricu- 
lar septum.  The  umbilical  eord  is  <|uite  straight,  and  is  inserted  into 
the  lower  part  of  the  abdomen.  Centres  of  ossification  are  showing 
themselves  in  the  inferior  maxillary  bones  on  the  clavicle. 

oil  inoiif/i. — The  embryo  weighs  from  70  to  300  gi'ains  and  measures 
from  2J  to  3^  inches  in  length.  The  forearm  is  well  formed,  and  the 
first  traces  of  the  fingers  can  be  made  out.  The  head  is  lai'ge  in  pro- 
portion to  the  rest  of  the  body,  and  the  eyes  are  prominent.  The  um- 
bilical vesicle  and  allantois  have  disappeared,  and  the  alimentary  canal 
is  now  situated  entirely  within  the  abdominal  cavity ;  the  greater  por- 
tion of  the  chorion  villi  have  atrophied,  and  the  })lacenta  is  distinctly 
formed. 

4tJt  month. — The  Mcight  is  from  4jo  6  ounces  and  the  length  about 
6- inches.  The  convolutions  of  the  brain  are  beginning  to  develop. 
The  sex  of  the  child  can  now  be  ascertained  on  inspection.  Hail's 
begin  to  be  formed  on  the  head.  The  muscles  are  sufficiently  formed 
to  ])roduce  distinct  movements  of  the  limbs.  Ossification  is  extending, 
and  can  be  traced  in  the  occipital  and  frontal  bones  and  in  the  mastoid 
processes.     The  sexual  organs  are  differentiated. 

5th  month. — "Weight,  about  10  ounces  ;  length,  9  or  10  inches.  Hair 
is  observed  covering  the  head,  which  forms  about  one-third  of  the 
length  of  the  whole  foetus.  The  nails  are  beginning  to  form,  and  ossi- 
fication has  commenced  in  the  isciiimn. 

6'th  month. — Weight,  about  1  pound  ;  length,  11  to  1'2.V  inches.  The 
!  hair  is  darker.  The  eyelids  are  closed,  and  the  menibrana  pu])illaris 
K  exists ;  eyelashes  have  now  been  formed.  Some  fat  is  de])osited  under 
\  the  skin.  The  testicles  are  still  in  the  abdominal  cavity.  The  clitoris  is 
prominent.     The  pubic  bones  have  begun  to  ossify. 

7th  month. — Weight,  from  3  to  4  pounds;  length,  13  to  15  inches. 
The  skin  is  covered  with  unctuous,  sebaceous  inatter,  and  there  is  a 
more  considerable  deposit  of  subcutaneous  fat.  The  eyelids  are  ojien. 
The  testicles  have  descended  into  the  scrotum. 

8th  month. — Weight,  from  4  to  5  pounds;  length,  16  to  18  inches, 
and  the  foetus  seems  now  to  grow  in  thickness  rather  than  in  length. 
The  nails  are  completely  develo})ed.  The  membrana  })upillaris  has 
disappeared. 

At  the  completion  of  pregnancy  the  fetus  weighs  on  an  average 
6^  ])ounds,  and  measures  about  211  iiiches  in  length.  These  averages 
are,  however,  liable  to  great  variation.  Remarkable  histories  are  given 
by  many  writers  of  foetuses  of  extraordinary  weight,  which  have  been 
probably  greatly  exaggerated.  Out  of  3000  children  delivered  under 
the  care  of  Cazeaux  at  various  charities,  one  only  weighed  10  pounds. 
There  are,  however,  several  carefully  recorded  instances  of  weight  far 
exceeding  this,  but  they  are  undoubtedly  nuich  more  uncommon  than 
is  generally  supposed.  Dr.  Kamsbottom  mentions  a  fVetus  weighing 
16J  pounds  ;  Cazeaux  tells  us  of  one  which  he  delivered  by  turning 
which  weighed  18  pounds  and  measured  2  feet  TJ  inches  ;  and  the 


THE  ANATOMY  AND  rilYSIOLOGY  OF  THE  FCETIJS.        12.3 

birth  of  one  Aveighlnf>;  21  pounds  lias  l)oen  recently  recorde*!.^  Such 
overthrown  children  are  almost   invariably  stillborn.^ 

The  average  size  of  male  children  at  birth,  as  in  after  life,  is  some- 
what greater  than  that  of  female.  Thus  Simpson^  found  that  out 
of  100  cases  the  male  children  averaged  10  ounces  more  in  weight 
than  the  female,  and  half  an  inch  more  in   length. 

[Some  mothers  of  average  size  invariably  bring  forth  very  small 
children,  never  having  one  near  an  average  weight.  Such  was  the  case 
with  a  lady  under  my  care,  whose  heaviest  male  infant,  now  a  vigorous 
boy  of  twelve  years,  weighed  5|  pounds.  A  female  child,  now  a  young 
lady,  weighed  3|  pouncls  ;  and  another  of  the  same  sex,  that  died  at 
eight  months,  weighed  only  2|  pounds.  It  grew  plump,  but  its  lower 
extremities  were  deficient  in  muscular  energy.  The  father  of  these 
children  is  of  average  height  and  weight. — Ed.] 

A  newborn  child  at  term  is  generally  covered  to  a  greater  or  less 
extent  with  a  greasy,  unctuous  material,  the  vcrnix  caseosa,  which  is 
formed  of  e^ilhelial^scales  and  the  secretion  of  the  sebaceous  glands, 
and  which  is  said  to  be  of  use  in  labor  by  lubricating  the  surface 
of  the  child.  The  head  is  generally  covered  with  long  dark  hair, 
which  frequently  falls  off  or  clianges  in  color  shortly  after  birth.  Dr. 
Wiltshire*  has  called  attention  to  an  old  observation,  that  the  eyes 
of  all  newborn  children  are  of  a  peculiar  dark  steel-gray  color,  and 
that  they  do  not  acquire  their  permanent  tint  until  some  time  after 
l)irtli.  The  umbilical  cord  is  generally  inserted  below  the  centre  of 
the  body. 

The  most  important  part  of  the  foetus  from  an  obstetrical  point 
of  view  is  the  head,  which  requires  a  separate  study,  as  it  is  the  usual 
j)resenting  part,  and  the  fecility  of  the  labor  depends  on  its  accurate 
adaptation  to  the  maternal  passages. 

Anatomy  of  the  Foetal  Head. — The  chief  anatomical  peculiarity 
of  interest  in  the  head  of  the  foetus  at  term  is  tliat  the  bones  of 
the  skull,  especially  of  its  vertex — which,  in  the  vast  majority  of  cases, 
has  to  pass  first  through  the  pelvis — are  not  firmly  ossified  as  in  adult 
life,  but  are  joined  loosely  together  by  membrane  or  cartilage.  The 
result  of  this  is  that  the  skull  is  capable  of  being  moulded  and  altered 
in  form  to  a  very  considerable  extent  by  the  pressure  to  which  it  is 
sul)jected,  and  thus  its  ])assage  through  the  pelvis  is  very  greatly  focili- 
tated.  This,  however,  is  chiefly  the  case  with  the  cranium  proper, 
the  bones  of  the  face  and  of  the  base  of  the  skull  being  more  firmly 
united.  By*  this  means  the  delicate  structures  at  the  base  of  the  brain 
are  protected  from  pressure,  while  the  change  of  form  which  the  skull 

1  Brit.  Med.  Journ.,  Feb.  1,  1879. 

'■^  Probably  the  largest  fa4us  on  record  was  that  of  Mrs.  Captain  Bates,  the  Nova 
Scotia  giantess,  a  woman  of  7  feet  9  inches,  whose  linsband  is  also  of  gigantic  build, 
reaching  7  feet  7  inches  in  lieight.  This  child,  born  in  Ohio,  was  their  second, 
and  was  lost  in  its  birth,  as  no  forcejis  could  be  procured  of  sufficient  size  to  grasp  the 
head.  The  foetus  weighed  284-  pomids.  and  was  ;>0  inches  in  length.  Their  first  infant 
weighed  18  pounds.  \Ve  have  had  children  born  in  this  city  (Philadelphia)  at  matu- 
rity and  live  that  weighed  but  one  pound.  The  well-remembered  "  Pincus  baby  " 
weighed  a  pound  and  an  ounce. — Harris,  note  to  3d  American  edition. 

^^^electcd  Oi.^'t.  Works,  p.  327.  *  Lancet,  February  11,  1871. 


124 


pnEGXAyry 


uiulcrgoc'S  (liiriiifj  lahor  inij)lic'at('.s  a  portion  of  tlio  skull  wliore  |»res- 
surc  oil  tlie  fraiiial  fontents  is  least  likely  to  be  injurious. 

The  divisions  between  the  bones  of  the  eraniuni  are  iurther  of  obstet- 
ric importance  in  enabling  us  to  detect  the  |)r('cise  jiosition  of  the  head 
during  labt»r,  and  an  accurate  knowledge  of  them  is  therefore  essen- 
tial to  the  obstetrician. 

^^'e  talk  of  them  as  sutures  and  fontanelleSy  the  former  being  the 
lines  of  junction  between  the  sej)arate  bones,  which  overlap  each  other 
to  a  greater  or  less  extent  during  labor;  the  latter  membranous  inter- 
spaces where  the  sutures  join  each  other. 

The  ])rincij)al  sutures  are — 1st.  ''J'he  sdf/itf'il,  which  separates  the  two 
parietal  bones,  and  extends  longitudinally  backward  along  the  vertex 
of  the  head.  2d.  Tht'fro)i(fil,  which  is  a  continuation  of  the  sagittal, 
and  divides  the  two  halves  of  the  frontal  bone,  at  this  time  separate 
from  each  other.  3d.  The  corona/,  which  separates  the  frontal  from  the 
parietal  bones,  and  extends  from  the  squamous  portion  of  the  temporal 
bone  across  the  head  to  a  corresponding  point  on  the  o])posite  side. 
And  4th,  the  lamhdoiilal,  which  receives  its  name  from  its  resemblance 
to  the  Greek  letter  J,  and  separates  the  occipital  from  the  parietal 
bones  on  either  side.     The  fontanelles  (Fig.  65)  are  the  membranous 


Fig.  Co. 


Fig.  66. 


Anterior  aud  Po.sterior  Fontan- 
elles. 


Bi-parietal  Dianuttr.  Sa;:iual  and 
I.anilidf)idal  Sutures,  with  Poste- 
rior Fontanelle. 


interspaces  where  the  sutures  join — the  anterior  and  largeV  being  loz- 
enge-shaped, and  formed  by  the  junction  of  the  frontal,  sagittal,  and 
two  halves  of  the  coronal  sutures.  It  will  be  well  to  note  that 
there  are,  therefore,  four  lines  of  sutures  running  into  it,  and  four 
angles,  of  Avhich  the  anterior,  formed  by  the  frontal  suture,  is  most 
elongated  and  well  marked.  The  posterior  fontanel le  (Fig.  6Q)  is 
formed  by  the  junction  of  the  sagittal  suture  with  the  two  legs  of  the 
lambdoidal.  It  is,  therefore,  triangular  in  sha])e,  Mith  three  lines  of 
suture  entering  it  in  three  angles,  and  is  much  smaller  than  the  anterior 
fontanello,  forminir  merely  a  depression  into  which  the  tip  of  the  finger 
can  be  placed,  while  the  latter  is  a  hollow  as  big  as  a  shilling  or  even 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        125 


larger.     As  it  is  tlie  posterior  foiitanellc  which  is  genei-ally  lowest,  and 

the  one  most  commonly  fijlt  during-  labor,  it  is  important  for  the  student 

to  familiarize  himself  with  it,  and  he  should  lose  no  oppf)rtunity  of 

studying  the  sensations  imparted  to  the  finger  by  the  sutures  and  fou-     ,     ,  "7  ^ 

taneiles  in  the  head  of  the  child  after  birth.      ,_-^— — ""  '  ^-<,j^^    jf^"'  '^  ' 

The  Diameters  of  the  Foetal  Skull. — For  the  purpose  of  under- 
standing the  mechanism  of  ]al)or,  we  nmst  study  the  measurements  of 
the  foetal  head  in  relation  to  the  cavity  through  which  it  has  to  pass. 
They  are  taken  from  corresponding  points  opposite  to  each  other,  and 
are  known  as  the  diameters  of  the  skull  (Fig.  67).  Those  of  most 
importance  are — 1st.    The  occipito- 

menf(i/is  (o.  m),  from  the  occipital  Fig.  67. 

protuberance  to  the  point  of  the 
chin,  5.25"  to  5.50".  2d.  The 
occipito-frontalis  (o.  f),  from  the 
occiput  to  the  centre  of  the  fore- 
head, 4.50"  to  5".  3d.  The  sub- 
occipito-brefjmafica  (s.  o.  b),  from  a 
point  midway  between  the  occipital 
])rotuberance  and  the  margin  of  the 
foramen  magnum  to  the  centre  of 
the  anterior  fontanelle,  3.25".  4th. 
The  cervico-bregmatica  (c.  b),  from 
the  anterior  margin  of  the  foramen 
magnum  to  the  centre  of  the  ante- 
rior fontanelle,  3.75".  5th.  Trans- 
verse or  bi-parietalis  (bi-p),  between 
the  parietal  protuberances,  3.75"  to 

4".    6th.  Bi-itemporalls  (bi-t),  between  the  ears,  3.50".    7th.  Fronto- 
mental'is  (f.  m),  from  the  apex  of  the  forehead  to  the  chin,  3.25". 

The  length  of  these  respective  diameters,  as  given  by  different  writers, 
differs  considerably,  a  fact  to  be  explained  by  the  measurements  having 
been  taken  at  different  times — by  some  just  after  birth,  when  the  head 
was  altered  in  shape  by  the  moulding  it  had  undergone ;  by  others 
when  this  had  either  been  slight  or  after  the  head  had  recovered  its 
normal  shape.  The  above  measurements  may  be  taken  as  the  average 
of  those  of  the  normally-shaped  head,  and  it  is  to  be  noted  that  the  first 
two  are  more  apt  to  be  modified  during  labor.  The  amount  of  compres- 
sion and  moulding  to  which  the  head  may  be  subjected  Mathout  proving 
fatal  to  the  fcetus  is  not  certainly  known,  but  it  is  doubtless  very  con- 
siderable. Some  interesting  examples  of  the  extent  to  which  the  head 
may  be  altered  in  shape  in  difficult  labors  have  been  given  by  Barnes/ 
M'ho  has  shown  by  tracings  of  the  shape  of  the  head  taken  innnediately 
after  delivery  that  in  protracted  labor  the  occipito-mental  (o.  m)  and 
occipito-frontal  (o.  f)  diameters  may  be  increased  more  than  an  inch  in 
length,  while  lateral  compression  may  diminish  the  bi-parietal  (bi-p) 
diameter  to  the  same  lengtli  as  the  interauricular.  The  foetal  head  is 
movable  on  the  vertical  column  to  the  extent  of  a  quarter  of  a  circle ; 
and  it  seems  probable  that  the  laxity  of  the  ligaments  admits  with 

'  Obd.  Trans.,  18(30,  vol.  vii.  p.  171. 


1  &  2.  Diameter  occipito-frontalis  (o.  f). 
3  &  4.  occipito-mentalis  (o.  m). 

5  &  6.  cervico-bregmatica  (c.  b). 

7  &  8.  fronto-mentalis  (f.  m). 


126  PREGyAyry. 

iiii|)unilv  a  ii;i'catc'r  ciivular  movciucnt   than  would   1)C  possible  in   the 
adult. 

( )n  takinu'  the  avc'i'ati:L'  of"  a  lar<ie  lUMuhor  ol"  niL-asiii-enicnts,  it  is 
inund  that  the  lieads  oi"  mak-  chihh'cn  aru  hir<!:cr  and  more  firmly  ossi- 
fied than  those  of"  females,  the  t"()rmer  avei-aiiin^- ahout  lialf'aii  inch  more 
in  cireumfi-rence.  Sir  James  Simj)son  attributed  threat  importanee  to 
this  faet,  and  believed  tlint  it  was  sufficient  to  account  for  tlie  lar»;cr 
jiroportion  of"  stillbirths  in  male  than  in  female  children,  as  well  as  for 
the  greater  difficulty  of  labor  and  the  increased  maternal  mortalitv  that 
are  f"ound  to  attend  on  male  bii'ths.  His  well-known  paper  on  this 
subject,  which  has  given  rise  to  much  controversy,  is  full  of  the  most 
elaborate  details;  and  so  great  did  he  believe  the  f"(etal  infiuence  to  be 
tliat  lie  calculated  that  between  the  years  1834  and  1837  there  were  lost 
in  Great  Britain,  as  a  consequence  of  the  slightly  larger  size  of  the  male 
than  of  the  female  head  at  birth,  about  50,000  lives,  including  those  of 
about  40,000  or  47,000  infants,  and  of  between  3000  and  4000  mothers 
who  died  in  childbed.^  It  is  ])robal)le  that  race  and  other  conditions, 
such  as  civih'/ation  and  intellectual  culture,  have  considerable  influence 
on  the  size  of  the  fcetal  skull,  but  we  are  uot  in  possession  of  sufficiently 
accurate  data  to  justify  any  very  positive  opinion  on  these  points. 
/  In  the  very  large  majority  of  cases  the  iinetus  lies  in  utero  with  head 
/downward,  and  is  so  ])laced  as  to  be  adapted  in  the  most  convenient  way 
\  to  the  cavity  in  which  it  is  ])laced.  The  uterine  cavity  is  most  roomy 
'  at  the  fundus,  and  narrowest  at  the  cervix,  and  the  greatest  bidk  of  the 
j  fot'tus  is  at  the  breech,  so  that  the  largest  part  of  the  child  usually  lies 
\  in  the  part  of  the  uterus  best  adapted  to  contain  it.  The  various  parts 
of  the  child's  body  are  further  so  placed,  in  regard  to  each  other,  as  to 
take  up  the  least  possible  amount  of  space.  (See  frontispiece.)  The 
body  is  bent  so  that  the  spine  is  curved  with  its  convexity  outward,  this 
curvature  existing  from  the  earliest  period  of  develoj)ment ;  the  chin  is 
flexed  on  the  sternum ;  the  forearms  are  flexed  on  the  arms,  and  lie 
close  together  on  the  front  of  the  chest ;  the  legs  are  flexed  on  the  thighs, 
and  the  thighs  drawn  up  on  the  abdomen  ;  the  feet  are  drawn  u]) 
toward  the  legs;  the  umbilical  cord  is  generally  placed  out  of  reach  of 
injurious  pressure  in  the  sjiaccs  between  the  arms  and  the  thighs. 
Variations  from  this  attitude,  however,  are  not  luicommon,  and  are  not, 
as  a  rule,  of  much  consequence.  Although  the  cranial  j)resentations  are 
much  the  most  common,  averaging  86  out  of  every  100  cases,  other 
presentations  are  by  no  means  rare,  the  next  most  frequent  being  either 
that  of  the  breech,  in  which  the  long  diameter  of"  the  child  lies  iu  the 
long  diameter  of  the  uterine  cavity,  or  some  variety  of  transverse  ])res- 
entation,  in  wliich  the  long  diameter  of  the  fietus  lies  obliquely  across  the 
uterus,  and  no  longer  corresjionds  to  its  longitudinal  axis. 

It  was  long  believed  that  the  head  jiresentation  was  only  assumed 
toward  the  end  of  pregnancy,  when  it  was  sujijiosed  to  be  jiroduced  by 
a  sudden  movement  on  the  ])art  of  the  fcetus,  known  as  the  culhufc  It 
is  now  well  knov.ii  that  in  the  large  majority  of  cases  the  head  is  lowest 
during  all  the  latter  })art  of  ])regnancy,  although  changes  in  position  are 
more  common  than  is  generally  believed  to  be  the  case,  and  presentation 
»  Selected  ObsL  Works,  p.  363. 


K 


THE  ANATO^fV  AND  rifVSfOLOGY  OF  THE  FCETUS. 


127 


of  parts  other  tliaii  the  liead  is  much  luon,'  fi'cquent  in  preniatnix'  labor 
than  ill  delivery  at  term.  In  evidence  of"  the  last  statement,  Churchill 
says  that  iu  labor  at  the  seventh  mouth  the  head  presents  only  83  times 
out  of  100  when  the  child  is  liviug,  and  that  as  many  as  53  per  cent, 
of  the  presentations  are  preternatural  when  the  child  is  stillborn.  The 
frequency  with  which  the  fetus  changes  its  position  before  delivery  lias 
been  made  the  subject  of  investigation  by  various  (iennan  obstetricians, 
and  the  fact  can  be  readily  ascertained  by  examination.  Valenta^  found 
that  out  of  nearly  1000  cases,  carefully  and  frequently  examined  by 
him,  in  57.6  per  cent,  the  presentation  underwent  no  change  in  the 
latter  months  of  pregnancy,  but  in  tlie  remaining  42.4  per  cent,  a 
change  could  be  readily  detected.  These  alterations  were  found  to  be 
most  frequent  in  nudtipara;,  aud  the  tendency  was  for  abnormal  presenta- 
tions to  alter  into  normal  ones.  Thus  it  was  common  for  transverse  presr 
€ntations'  to  alter  longitudinally,  and  but  rare  for  breech  presentations  to 
change  into  head.  The  ease  with  which  these  changes  are  effected  r.o 
doubt  depends,  in  a  considerable  degree,  on  the  laxity  of  the  uterine 
]>arietes  and  on  the  greater  quantity  of  amniotic  fluid,  by  both  of  which 
the  free  mobility  of  the  fa?tus  is  favored. 

The  facility  with  which  the  position  of  the  fcetns  in  utero  can  be 
ascertained  by  abdominal  palpation  has  not  been  generally  appreciated 
in  obstetric  works,  aud  yet  by  a  little  practice  it  is  easy  to  make  it  out. 
Much  information  of  importance  can  be  gained  in  this  way,  and  it  is 
quite  possible,  under  favorable  circumstances,  to  alter  abnormal  pres- 

FiG.  68. 


Mode  of  Ascertaining  the  Position  of  the  Foetus  by  Palpation. 

eutations  before  labor  has  begun.  For  the  purpose  of  making  this 
examination  the  patient  should  lie  at  the  edge  of  the  bed,  with  her 
shoulders  slightly  raised  and  the  abdomen  uncovered.     The  first  obser- 

'  Mm.  f.  Geburf.,  1865,  Bd.  xxiv.  S.  172;  aiul  186G,  Bd.  xxviii.  S.  3(31:  "  Gebiirts- 
hiilfliche  Studien." 


128  PREGNASCY. 

vation  to  make  is  to  see  if  tlie  loiifritudinal  axis  of  the  uterine  tumor 
(.•orrcspoiuls  with  that  of  tlie  mother's alKloiiien  ;  if  it  does,  the  presenta- 
tion must  l)e  either  a  head  or  a  breeeli.  Jiy  spreadinj::  the  hands  over 
the  uterus  (Fig.  OS)  a  greater  sense  of  resistance  can  be  fch,  in  most 
cases,  on  one  side  than  on  the  otlier,  eorresj)on(ling  to  the  back  of  the 
child.  By  striking  the  tips  of  the  fingers  suddenly  inward  at  the  fundus, 
the  hard  breech  can  generally  be  made  out,  or  the  head  still  inore  easily 
if  the  breech  be  dow invard.  AVhen  the  uterine  wall^  are  unusually  lax 
it  is  often  possible  to  feel  the  limbs  of  the  cliild.  'These  observations 
can  be  generally  corroborated  by  anscultation,  ibr  in  head  presentations 
the  fcetal  heart  can  u.-;ually  be  heard  belowThe  umbilicus,  and  in  breech 
cases  above  it.^  Transversepi'esentations  can  even  more  easily  be  made 
out  by  abdominal  palpation.  'Here  the  long  axis  of  the  uterine  tumor 
does  not  corresjjcnd  with  the  long  axis  of  the  mother's  abdomen,  but 
lies  obliquely  across  it.  By  pal})ation  the  rounded  mass  of  the  head  wni 
be  easily  felt  in  one  of  the  mother's  flanks,  and  the  breech  in  the  other, 
while  the  fcetal  heart  is  heard  pulsating  nearer  to  the  side  at  which  the 
head  is  detected. 

Tlie  reason  why  the  head  presents  so  frequently  has  been  made  the 
subject  of  much  discussion.  The  oldest  theory  was,  that  the  head  lay 
over  the  os  uteri  as  the  result  of  ^^^g^ jj^tion,  aiid  the  influence  of  gravity, 
although  contested  by  man^'^ot'stetricians,  prominent  among  whom  were 
Dubois  and  Simpson,  has  ])een  insisted  upon  as  the  chief  cause  by 
others.  Dr.  Duncan  being  one  of  the  most  strenuous  advocates  of  this 
view.  The  objections  urged  against  the  gravitation  theory  Avere  drawn 
partlv  from  the  result  of  exjieriments,  and  partly  from  the  frequency 
witli  which  abnornal  presentations  occur  in  premature  lal)ors,  when  the 
action  of  gravity  cannot  be  supposed  to  be  susjjended.  The  experi- 
ments made  by  Dubois  M-ent  to  show  that  when  the  foetus  was 
suspended  in  water  gravitation  caused  the  shoulders,  and  not  the 
head,  to  fall  lowest.  (He  therefore  advanced  the  hypothesis  that  the 
position  of  the  fcetus  was  due  to  instinctive  movements  which  it  made 
to  adapt  itself  to  the  most  comfortable  position  in  which  it  could  lie.  It 
need  only  be  remarked  that  there  is  not  the  slightest  evidence  of  the 
fcetus  possessing  any  such  power.")  Simpson  proposed  a  theory  which  was 
much  more  plausible.  (He  assu/ned  that  the  foetal  position  was  due  to 
reflex  movements  produced  by  ]ihysical  irritations  to  which  the  cutane- 
ous surface  of  the  foetus  is  subjected  from  changes  of  the  mother's 
position,  uterine  contractions,  and  the  like.  J  The  absence  of  these 
movements,  in  the  case  of  the  death  of  the  tcetus,  would  readily  ex- 
plain the  frequency  of  mal-presentations  under  such  circumstances. 
The  obvious  objection  to  this  theory,  complete  as  it  seems  to  be,  is  the 
absence  of  any  proof  that  such  constant  extensive  reflex  movements 
reallv  do  occur  in  utero.  Dr.  Duncan  has  very  conclusively  disposed 
of  the  principal  objections  which  have  l)een  raised  against  the  influence 
of  gravitation,  and  when  an  obvious  explanation  of  so  simple  a  kind 
exists  it  seems  useless  to  seek  farther  for  another.  He  has  sho-wn  that 
Dubois'  experiments  did  not  accurately  represent  the  state  of  the  foetus 
in  utero,  and  that  during  the  greater  part  of  the  day,  wiien  the  woman 
is  upright  or  lying  on  lier  back,  the  foetus  lies  obliquely  to  the  horizon 


TILE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        129 

at  an  angle  of  about  30°.  The  child  thus  lies,  in  the  former  case,  on  an 
inclined  plane  formed  by  the  anterior  uterine  wall  and  by  the  abdomi- 
nal parietes ;  in  the  latter,  by  the  posterior  uterine  wall  and  the 
vertebral  column.     Down  the  inclined  plane  so  formed  the  force  of 


Diagram  illustrating  the  Effect  of  Gravity  on  the  Foetus.    (After  Duncan.) 

6,  is  parallel  to  the  axis  of  the  pregnant  uterus  and  pelvic  brim,    c,  d,  e.  Is  a  perpendicular  line. 
centre  of  gravity  of  the  foetus,     d,  the  centre  of  flotation. 


the 


gravity  causes  the  foetus  to  slide,  and  it  is  only  when  the  woman  lies  on 
her  side  that  the  foetus  is  placed  horizontally,  and  is  not  subjected  in  the 
same  degree  to  the  action  of  gravity  (Fig.  69).  The  frequency  of  mal- 
presentations  in  premature  labors  is  explained  by  Dr.  Duncan  partly  by 


Fig.  70. 


Illustrating  the  Greater  Mobility  of  the  Fcetus  and  the  Larger  Relative  Amount  of  Liquor 
Amnii  in  Early  Pregnancy.     (After  Duncan.) 

«,  6.  Axis  of  pregnant  uterus.  h,  h.  A  horizontal  line. 

the  fact  that  the  death  of  the  child  (^yhich  so  frequently  precedes  such 
cases)  alters  its  centre  of  gravity,  and  partly  by  the  greater  mobility  of 
the  child  and  the  greater  relative  amount  of  liquor  amnii  (Fig.  70). 
The  influence  of  gravitation  is  probably  p^reatly  assisted  by  the  contrac- 


130  PREGNANCY. 

tjons  9f  flip  iitpriT^  wlnVli  arc  guing  on  during  the  greater  })art  of  preg- 
nancy. The  influence  of  tliese  was  j)ointc(l  out  by  Dr.  Tyler  Smith, 
■who  distinctly  showed  that  the  contractions  of  the  uterus  preceding 
delivery  exerted  a  moulding  or  adapting  influence  on  the  fretus  and 
prevented  undue  alterations  of  its  jjosition.  Dr.  Hicks  proved'  that 
these  uterine  contractions  are  of  constant  occurrence  from  the  earliest 
period  of  pregnancy,  and  there  can  be  little  doubt  that  they  must  have 
an  important  influence  on  the  body  contained  within  the  uterus.  The 
whole  subject  has  been  recently  considered  by  Pinard,^  who  shows  that 
many  factors  are  in  action  to  produce  and  maintain  the  usual  position 
of  the  foetus  in  utero,  which  may  be  either  of  an  active  or  a  j)assive 
character:  the  former  being  chiefly  the  active  movements  of  the  fretus 
and  the  contractions  of  the  uterus  and  the  abdominal  muscles ;  the 
latter,  the  form  of  the  uterus  and  the  foetus,  the  slippery  surface  of  the 
amnion,  pressure  of  the  amniotic  fluid,  etc.  When  any  of  these  factor's 
are  at  fault  mal-presentation  is  apt  to  occur. 

The  functions  of  the  fcetus  are  in  the  main  the  same,  with  differences 
depending  on  the  situation  in  which  it  is  placed,  as  those  of  the  sepa- 
rate being.  It  breathes,  it  is  nourished,  it  forms  secretions,  and  its 
nervous  system  acts.  The  mode  in  which  some  of  these  functions  are 
carried  on  in  intra-uterine  life  requires  separate  consideration. 

Nutrition. — During  the  early  part  of  jDregnancy,  and  before  the 
formation  of  the  umbilical  vesicle  and  the  allantois,  it  is  certain  that 
nutritive  material  must  be  supplied  to  the  ovum  by  endosmosis  through 
its  external  envelope.  The  precise  source,  however,  from  which  this  is 
obtained  is  not  positively  known.  By  some  it  is  believed  to  be  derived 
from  the  granulations  of  the  discus  pi-oluierus  which  surround  it  as  it 
escapes  from  the  Graafian  follicle,  ana  suTJsequently  from  the  layer  of 
albuminous  matter  which  surrounds  the  ovum  before  it  reaches  the 
uterus ;  while  others  think  it  probable  that  it  may  come  from  a  special 
liquid  secreted  by  the  interior  of  the  Fallopian  tube  as  the  ovum 
passes  along  it.  As  soon  as  the  ovum  has  reached  the  uterus  there  is 
every  reason  to  believe  that  the  umbilical  vesicle  is  the  chief  source  of 
nourishment  to  the  embryo  through  the  cnanneTof  the  omphalo-mesen- 
teric  vessels,  which  convey  matters  absorbed  from  the  interior  of  the 
vesicle  to  the  intestinal  canal  of  the  foetus.  At  this  time  the  exterior 
of  the  ovum  is  covered  by  the  numerous  fine  villosities  of  the  primi- 
tive chorion,  which  are  imbedded  in  the  mucous  membrane  of  the 
uterus ;  and  it  is  thought  that  they  may  absorl)  materials  from  the 
maternal  system,  which  may  be  either  directly  absorbed  l)y  the  cnd)rvo 
or  which  may  serve  the  purpose  of  replacing  the  nutritive  matter  which 
has  been  removed  from  the  umbilical  vesicle  by  tlKMimphalo-mesenteric 
vessels.  This  point  it  is  of  course  impossible  to  decide.  Joulin,  how- 
ever, thinks  that  these  villi  probably  have  no  direct  influence  on  the 
nourishment  of  the  fictus,  which  is  at  this  time  solely  eflected  by  the 
umbilical  vesicle,  but  that  they  absorb  fluid  from  the  materiial  system, 
which  passes  through  the  amnion  and  fornix  the  li(|Uor  amnii.  As  soon 
as  the  allantois  is  developed,  vascular  connnunication  between  the 
foetus  and  the  maternal  structures  is  established,  and  the  temporary 

^  Obst.  Trans.,  1872,  vol.  xiii.  p.  216.  Annal.  de  Gyn.,  1878,  torn.  ix.  p.  321. 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        131 

i'liiKitiou  of  the  umbilical  vesicle  is  over;  that  structure,  therefore, 
rapidly  atrophies  and  disappears,  and  the  nutrition  of  the  foetus  is  now 
solely  carried  on  by  means  of  the  chorion  villi,  lined  as  they  now  are 
by  the  vascular  endochorion,  and  chiefly  by  those  which  go  to  form  the 
substance  of  the  placenta. 

This  statement  is  o})posed  to  the  views  of  many  ])hysiologists,  who 
believe  that  a  certain  amount  of  nutritive  material  is  conveyed  to  the 
fnetus  through  the  channel  of  the  liquor  amnii,  itself  derived  from  the 
maternal  system,  which  is  supposed  either  to  be  absorbed  through  the 
cutaneous  surface  of  the  fetus  or  carried  to  the  intestinal  canal  by 
deglutition.  The  reasons  for  assigning  to  the  liquor  amnii  a  nutri- 
tive function  are,  however,  so  slight  that  it  is  difficult  to  believe  that  it 
has  any  apprecialile  action  in  this  way.  They  are  based  on  some 
questionable  observations,  such  as  those  of  Weydlich,  who  kept  a 
calf  alive  for  fifteen  days  by  feeding  it  solely  on  liquor  amnii;  and  the 
experiments  of  Burdach,  who  found  the  cutaneous  lymphatics  engorged 
in  a  foetus  removed  from  the  amniotic  cavity,  while  those  of  the  intes- 
tine were  empty.  The  deglutition  of  the  liquor  amnii  for  the  purposes 
of  nutrition  have  been  assumed  from  its  occasional  detection  in  the 
stomach  of  the  foetus,  the  presence  of  which  may,  however,  be  readily 
explained  by  spasmodic  efforts  at  respiration  which  the  foetus  undoubt- 
edly often  makes  before  birth,  especially  when  the  placental  circulation 
is  in  any  way  interfered  with,  and  during  which  a  certain  quantity  of 
fluid  would  uecessarily  be  swallowed.  The  quantity  of  nutritive 
material,  however,  in  the  liquor  amnii  is  so  small — not  more  than  6 
to  9  parts  of  albumen  in  1000 — that  it  is  impossible  to  conceive  how  it 
could  have  any  appreciable  influence  in  nutrition,  even  if  its  absorption 
either  by  the  skin  or  stomach  were  susceptible  of  proof. 

That  the  nutrition  of  the  foetus  is  effected  through  the  placenta  is 
proved  by  the  coaunon  observation  that  whenever  the  placental  circula- 
tion is  arrested,  as  by  disease  of  its  structure,  the  foetus  atrophies  and 
dies.  The  precise  mode,  however,  in  which  nutritive  materials  are 
absorbed  from  the  maternal  blood  is  still  a  matter  of  doubt,  and  must 
remain  so  until  the  mooted  points  as  to  the  minute  anatomy  of  the  pla- 
centa are  settled.  The  various  theories  entertained  on  this  subject  by 
the  upholders  of  the  Hunterian  doctrine  of  placental  anatomy,  and  by 
those  who  deny  the  existence  of  a  sinus  system,  have  already  been 
referred  to  in  the  chapter  on  the  Anatomy  of  the  Placenta,  to  which  the 
reader  is  referred  (pp.  114-120). 

Respiration. — One  of  the  chief  functions  of  the  placenta,  besides 
that  of  nutrition,  is  the  supply  of  oxvgenated  blood  to  the  foetus.  ;  That 
this  is  essential  to  the  vitality  of  the  foetus,  and  that  the  placenta  is  the 
site  of  oxygenation,  is  shown  by  the  fact  that  whenever  the  placenta  is 
separated,  or  the  access  of  the  foetal  blood  to  it  arrested  by  compression 
of  the  cord,  instinctive  attempts  at  inspiration  are  made,  and  if  aerial 
respiration  cannot  be  performed  the  foetus  is  exjielled  asphyxiated. 
Like  the  other  functions  of  the  foetus  during  intra-uterine  life,  that  of 
respiration  has  been  made  the  subject  of  numerous  more  or  less  inge- 
nious hypotheses.  Thus,  many  have  believed  that  the  foetus  absorbed 
gaseous  material  from  the  liquor  amnii,  which  served  the  purpose  of 


132  pjiJ':(;yAycy. 

oxvi;t'Matin<;  its  l)loo(l — St.  Ilihiin;  thiiikintr  tliat  this  was  effected  Iw 
niimitc  opeiiir.trs  in  its  sUiii,  JJrcianl  aii<l  others  thn)iioh  tlie  l)r(>iiehi,  to 
whieh  tliey  believed  the  licjiior  ainiiii  j^ained  access.  Jndependently  of 
the  entire  want  of  eviilence  of  tiie  absorption  of  ga.seou.s  materials  jjy 
these  channels,  the  theory  is  disproved  by  the  fact  that  the  liquor  aninii 
contains  no  air  which  is  capable  of  respiratit)n.  Serres  attributed  a  sim- 
ilar finiction  to  some  of  the  chorion  villi,  which  he  believed  peneti'ated 
the  utricular  Lrhmds  of  the  decidua  rcHexa  and  absorbed  <ras  from  the 
hydr()[)crione,  or  Huid  situated  between  it  and  the  decidua  vera ;  and 
in  this  juanner  he  thought  the  fetal  blood  was  oxygenated  until 
tiie  fifth  montli  of  intra-uterine  life,  when  the  placenta  was  fully 
formed. 

This  liypothesis,  however,  rests  on  no  accurate  foundation,  for  it  is 
certain  that  the  chorion  villi  do  not  penetrate  the  utricular  glands  in  the 
manner  assumed  ;  or,  even  if  they  did,  the  mode  in  which  the  oxygen 
thus  absorbed  by  the  cliorion  villi  reaches  the  foetus,  which  is  se})arated 
from  them  by  the  amnion  and  its  contents,  would  still  remain  unex- 
plained. 

The  mode  in  which  the  oxygenation  of  the  foetal  blood  is  effected 
^before  the  formation  of  the  placenta  remains,  therefore,  as  yet  unknown. 
After  the  development  of  that  organ,  hoM'ever,  it  is  less  difficult  to 
understand,  for  the  fa?tal  blood  is  eveiTMhere  brought  into  such  close 
contact  with  the  maternal  in  the  numerous  minute  ramifications  of  the 
umbilical  vessels  that  the  interchange  of  gases  can  readily  be  effected. 
Tlie  activity  of  respiration  is  doubtless  much  less  than  in  extra-uterine 
life,  for  the  waste  of  tissue  in  the  foetus  is  necessarily  comi)aratively 
small,  from  the  fact  of  its  being  suspended  in  a  fluid  medium  of  its 
own  temperature,  and  from  the  absence  of  the  processes  of  digestion 
and  of  respiratory  movements.  The  quantity  of  carbonic  acid 
formed  would,  therefore,  be  much  less  than  after  birth,  and  there 
would  be  a  correspondingly  small  call  for  oxygenation  of  venous 
circulation. 

Circulation. — The  functions  of  the  lungs  being  in  abeyance,  it  is 
necessary  that  all  the  foetal  blood  should  be  carried  to  the  placenta 
to  receive  oxygen  and  nutritive  materials.  To  understand  the  mode 
in  which  this  is  effected  we  must  bear  in  mind  certain  peculiarities 
in  the  circulatory  system  which  disappear  after  birth. 

1.  The  two  sides  of  the  foetal  heart  are  not  separate  as  in  the  adult. 
The  right  ventricle  in  the  adult  sends  all  the  venous  l)lood  to  the  lungs 
through  the  pulmonary  arteries,  to  be  aerated  by  contact  with  the 
atmosphere.  In  the  foetus,  hoM'ever,  only  sufficient  blood  is  passed 
through  the  jiulmonaiy  arteries  to  ensure  their  being  pervious  and 
readv  to  carry  l)lood  to  the  lungs  immediately  after  birth. 

An  aperture  of  communication,  the  foi-a mrn  o;y//c,  exists  between  the 
two  auricles,  which  is  arranged  so  as  to  permit  the  blood  reaching  the 
right  auricle  to  pa.ss  freely  into  the  left,  l)ut  not  rice  versd.  By  this 
means  a  large  portion  of  the  blood  reaching  the  heart  through  the 
venfe  cavfe,  instead  of  passing,  as  in  the  adult,  into  the  right  ventricle, 
is  directed  into  the  left  auricle. 

2.  Even  with  this  arrangement,  however,  a  lai-ger  portion  of  blood 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  Fd'JTUS.        133 

would  pass  into  the  jiiilnionary  arteries  than  is  required  for  transmis- 
sion to  the  lungs,  and  a  further  provision  is  made  to  prevent  its  going 
to  them  by  means    of  a    fa'tal    vessel,    the  ductus 
arteriosus  (Fig.  71),  which  arises  from  the  ])ointof  Fig.  71. 

bifurcation  of  the  pulmonary  arteries  and  opens 
into  the  arch  of  the  aorta.  In  consequence  of  this 
arrangement  only  a  very  small  portion  of  the 
blood  reaches  the  lungs  at  all. 

3.  The  fatal  hypogastric  arteries  are  continued 
into  large  arterial  truidvs,  which,  passing  into  the 
cord,  form  the  umbUlccd  arteries  and  carry  the 
impure  foetal  blood  into  the  placenta.  Diagram  of  Foetai  Heart. 

4.  The  purified  blood  is  collected  into  the  single  (-^"^r  Daiton.) 
nmhilieal  vein,  through  which  it  is  carried  to  the  2.  Pulmonary  artery. 
under  surface  of  the  liver,  from  which  point  it  is  ':  DucttTrterToB'^'r'''''' 
conducted,  by  means  of  another  special  foetal  vessel, 

the  ductus  venosus,  into  the  ascending  vena  cava  and  the  right  auricle. 

In  order  to  understand  the  course  of  the  foetal  blood,  it  may  be  most 
conveniently  traced  from  the  point  where  it  reaches  the  under  surface 
of  tlie  liver  through  the  umbilical  vein.     Part  of  it  is  distributed  to  the 
liver  itself,  but  the  greater  quantity  is  carried  directly  into  the  inferior 
vena  cava  through  the  ductus  venosus.     The  inferior  vena  cava  also 
receives  the  blood  from  tlie  foetal  veins  of  the  lower  extremities  and 
that  portioiL  of  the  blood  of  the  umbilical  vein  which  has  passed  through 
the  liver.    [This  mixed  blood  is  carried  up  to  the  right  auricle,  from\ 
which  by  far  the  greater  part  of  it  is  immediately  directed  into  the  i 
left  auricle  through  the  foramen  ovale.     Thence  it  passes  into  the  left  ' 
ventricle,  M'hich  sends  the  greater  part  of  it  into  the  head  and  upper  . 
extremities  through  the  aorta,  a  comparatively  small  quantity  being  / 
transmitted  to  the  inferior  extremities.     The  blood  which  is  thus  sent  1 
to  the  upper  part  of  the  body  is  collected  into  the  vena  cava  superior,  I 
by  which  it  is  thrown  into  the  right  auricle.     Here  the  mass  of  it  is  ! 
probably  directed   into  the    right   ventricle,  which    expels   it  into  the 
pulmonary  arteries,  and    thence,   through    the  ductus  arteriosus,  into 
the  descending  aorta,  j    By  this  arrangement  it  will  be  seen   that  the 
descending  aorta  conveys  to  the  lower  part  of  the  body  the  compara- 
tively impure  blood  which  has  already  circulated  through  the  head, 
neck,  and  upper  extremities.     From  the  descending  aorta  a  small  quan- 
tity of  blood  is  conveyed  to  the  lower  extremities,  the  greater  part  of 
it  being  carried  for  purification  to  the  placenta  through   the  umbilical 
arteries. 

As  soon  as  the  child  is  born  it  generally  cries  loudly  and  inflates  its 
lungs,  and,  in  consequence,  the  pulmonary  arteries  are  dilated,  and 
the  greater  portion  of  the  blood  of  the  right  ventricle  is  at  once  sent 
to  the  lungs,  whence,  after  being  arterialized,  it  is  returned  to  the  left 
auricle  through  the  pulmonary  veins.  The  left  auricle,  therefore, 
receives  more  blood  than  before,  the  riglit  less,  and,  the  [placental  ciix-u- 
lation  being  arrested,  no  more  passes  through  the  umbilical  vein.  In 
consequence  of  this,  the  i^ressure  of  the  blood  in  the  two  auricles  is 
equalized ;  the  mass  of  the  blood  in  the  right  auricle  no  longer  passes 


r  fc^v 


134  '    P 


Fig.  72. 


into  the  lel't  (the  valve  ol"  the  lunuueii  ovale  heinj^  elo.sed  hy  tjje  equal 
pressure  on  both  sides),  but  directly  into  the  right  ventricle,  and  thence 
into  the  ])ulnioiiary  arteries,  and  the  ductus  arteriosus  soon  collaj).ses 
and  becomes  impervious.  The  ma.ss  of"  blood  in  the  dcst-ending  aorta 
no  longer  finds  its  way  into  the  hyp( (gastric  arteries,  but  ])a>ses  into 
the  lower  extremities,  and  the  adult  circulation   is  established. 

The  changes  which  take  place  in  the  temporary  va.scular  arrange- 
ments of  the  fVetus  prior  to  their  complete  di.sajjpearance  are  of  .some 
jiractical  interest.  TlH3_jiiK^:tji,^.Uit(il'iQsus,  as  has  been  .said,  collap.ses, 
chiefly  because  the  nia.ss  of  blood  is  drawn  to  the  lung.s,  and  partlv, 
])erhaps,  by  its  own  inherent  contractility.  Its  walls  are  fomxl  to  be 
thickened,  and  its  canal  clo.ses,  fir.st  in  the  centre,  and  subsequently 
at  its  extremitie.s,  its  aortic  end  remaining  pervious  longer  on  account 
of  the  greater  pressure  of  blood  from  the  left  side  of  the  heart  (Fig.  72). 

Practical  closure  occurs  within  a  few  days 
after  birth,  although  Flourens  states  that  it 
is  not  completely  obliterated  until  eighteen 
months  or  two  years  have  elai)sed.'  Accord- 
ing to  Schroeder,  its  walls  unite  without  the 
<^<^  formation  of  any  thrombus.  The  foramen 
ovale  is  soon  closed  by  its  valve,  which  con- 
tracts adhesion  with  the  edges  of  the  a])er- 
ture,  so  as  effectually  to  occlude  it.  Some- 
times, however,  a  small  canal  of  connnuni- 
cation  between  the  two  auricles  may  remain 
pervious  for  many  months,  or  even  a  year 
and  more,  without,  however,  any  admixture 
of  blood  occurring.  A  permanently  jnitu- 
lous  condition  of  this  a])erture,  however, 
sometimes  exists,  giving  rise  to  the  disea.'^e 
known  as  cyanosis. 
The  umbilical  ai'teries  and  veins  and  the  ductus  venosus  soon  also 
become  impermeable,  in  consequence  of  concentric  hypertrophy  of  their 
tissue  and  collap.se  of  their  walls.  The  closure  of  the  former  is  aided 
by  the  formation  of  coagnla  in  the  intei'ior.  According  to  Kobin,  a 
longer  time  than  is  n.sually  supjio.'^ed  elap.'^es  before  they  become  com- 
])letely  elo.sed,  the  vein  remaining  pervious  until  the  twentieth  or 
thirtieth  day  after  delivery,  the  arteries  for  a  month  or  six  weeks. 
He  has  al.so  flescribed  ^  a  remarkable  contraction  of  the  umbilical 
ve.'Jsels  within  their  sheaths  at  the  point  where  they  leave  the  abdomi- 
nal walls,  which  takes  place  within  three  or  four  days  after  birth,  and 
seems  to  prevent  henK)rrhage  taking  place  when  the  cord  is  detached. 

Thc_lr\'er,  from  its  ])roportionately  large  size,  ap]xn-ently  jdays  an 
important  jiart  in  the  fVctal  economy.  It  is  not  until  about  the  fifth  month 
of  utero-gestation  that  ita.ssumes  its  characteristic  structure  and  forms  bile, 
previous  to  that  time  its  texture  being  .<oft  and  undcvclojied.  Accord- 
ing to  Claude  IJcrnard,  after  this  ]>criod  one  of  its  most  impoi'tant  offices 
is  the  formation  of  sugar,  which  is  found  in  much  larger  amount  in  the 
foetus  than  after  birth.     Sugar  is,  however,  found  in  the  foetal  structures 

1  Acad,  des  Sciences,  1854.  *  Ibid.,  1860. 


Diagram  of  Heart  of  Infant. 

(After  Dalton.) 

1.  Aorta.  2.  Pulmonary  artery. 

3.  3.  Piilinonnrj'  brandies. 

4.  Dnrtus  arteriosus  beconiiug  oblite- 
rated. 


I 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FOETUS.        135 

long  before  the  development  of  the  liver,  especially  in  the  mucous  and 
cutaneous  tissues;  and  it  seems  probable  that  these,  as  well  as  the  jila- 
centa  itself,  then  fulfil  the  glycoj^enic  function,  afterward  chiefly  per- 
formed by  the  liver.  The  bile  is  secreted  after  (Ik;  fifth  month  of  [),rcg- 
nancy,  and  passes  into  the  intestinal  canal,  and  is  subsequently  collected 
inTTie  o:all-bladder.  By  some  physiologists  it  has  been  supposed  that 
the  liver,  during  intra-uterine  life,  was  the  chief  seat  of  depuration  of 
the  carbonic  acid  contained  in  the  venous  blood  of  tlie  foetus.  It  is, 
however,  more  generally  believed  that  this  is  accomplished  solely  in  the 
placenta.  The  bile,  mixed  with  the  mucous  secretion  of  the  intestinal 
tract,  forms  the  meconiimi  which  is  contained  in  the  intestines  of  the 
foetus,  and  whicli"~collects  in  them  during  the  whole  period  of  intra- 
uterine life.  It  is  a  thick,  tenacious,  greenish  substance,  which  is  voided 
soon  after  birth  in  considerable  quantity. 

■Urine  is  certainly  formed  during  intra-uterine  life,  as  is  proved  by 
the  fact,  familiar  to  all  accoucheurs,  that  the  bladder  is  constantly 
emptied  instantly  after  birth^  It  has  generally  been  supposed  that  the 
foetus  voids  its  urine  into  the  cavity  of  the  amnion ;  and  the  existence 
of  traces  of  urea  in  the  liquor  amnii,  as  well  as  some  cases  of  imperfo- 
rate urethra  in  which  the  bladder  was  found  to  be  enormously  distended, 
and  some  cases  of  congenital  hydronephrosis  associated  with  impervious 
ureters,  have  been  supposed  to  corroborate  this  assumption.  The  ques- 
tion has  been  very  fully  studied  by  Joulin,  who  has  collected  together  a 
large  number  of  instances  in  which  there  was  imperforate  urethra  with- 
out any  undue  distension  of  the  bladder.  He  holds,  also,  that  the 
amount  of  urea  found  in  the  liquor  amnii  is  far  too  minute  to  justify  the 
conclusion  that  the  urine  of  the  foetus  was  habitually  passed  into  it, 
although  a  small  quantity  may,  he  thinks,  escape  into  it  from  time  to 
time;  and  he  therefore  believes  that  the  urine  of  the  foetus  is  only 
secreted  regularly  and  abundantly  after  birth,  and  that  during  intra- 
uterine life  its  retention  is  not  likely  to  give  rise  to  any  functional 
disturbance.^ 

Function  of  the  Nervous  System. — There  is  no  doubt  that  the 
nervous  system  acts  to  a  considerable  extent  during  intra-uterine  life, 
and  some  authors  have  even  supposed  that  the  foetus  was  endowed  with 
the  power  of  making  instinctive  or  voluntary  movements  for  the  pur- 
pose of  adapting  itself  to  the  form  of  the  uterine' cavity.  (  Most  probably, 
however,  the  movements  the  foetus  performs  are  purely  reflex^  That 
it  responds  to  a  stimulus  applied  to  the  cutaneous  nerves  is  proved  by 
the  experiments  of  Tyler  Smith,  who  laid  bare  the  amnion  in  pregnant 
rabbits,  and  found  that  the  foetus  moved  its  limbs  when  these  were  irri- 
tated through  it.  Pressure  on  the  mother's  abdomen,  cold  applications, 
and  similar  stimuli  will  also  produce  energetic  foetal  movements. 
The  gray  matter  of  the  brain  in  the  newborn  child  is,  however,  quite 
rudimentary  in  its  structure,  and  there  is  no  evidence  of  intelligent 
action  of  the  nervous  system  until  some  time  after  birth,  and,  a  fortiori, 
during  pregnancy. 

^Acad.  des  Sciences,  p.  308. 


lo6  PREGNANCY. 


CHAPTER   III. 
PREGNAN'CY. 

Changes  in  the  Uterus. — As  soon  as  fonooj^tion  has  takoii  place  a 
series  ot"  remarkable  changes  commence  in  the  uterus,  Avhich  progi-ess 
until  the  termination  of  pregnancy,  and  are  well  worthy  of  careful 
study.  They  produce  those  marvellous  modifications  which  effect  the 
transformation  of  the  small  undevelojjcd  uterus  of  the  non-pregnant 
state  into  tlie  large  and  fully-dcN-eloped  uterus  of  pregnancy,  and  have 
no  parallel  in  the  w'hole  animal  economy. 

A  knowledge  of  them  is  essential  for  the  proper  comprehension  of 
the  phenomena  of  labor,  and  for  the  diagnosis  of  j)regnancy  which  the 
practitioner  is  so  frequently  called  upon  to  make.  Excluding  the  varie- 
ties of  abnormal  pregnancy,  which  "will  l)e  noticed  in  another  place,  we 
shall  here  limit  ourselves  to  the  consideration  of  the  modifications  of  the 
maternal  organism  which  result  from  simple  and  natural  gestation. 

The  unimpregnated  uterus  measures  2J  inches  in  length,  and  weighs 
about  1  ounce,  while  at  the  full  term  of  pregnancy  it  has  so  immensely 
grown  as  to  weigh  24  ounces  and  measure  12  inches.  The  growth  com- 
mences as  soon  as  the  ovum  reaches  the  uterus,  and  continues  uninter- 
ruptedlv  until  deliveiy.  In  the  early  months  the  uterus  is  contained 
entirelv  in  the  cavity  of  the  pelvis,  and  the  increase  of  size  is  only 
apparent  on  vaginal  examination,  and  that  with  difficulty,  (  Before  the 
third  month  the  enlargement  is  chiefly  in  the  lateral  direct  ion,)  so  that 
the  whole  body  of  the  uterus  assumes  more  of  a  -2)herical  sha])e  than  in 
the  non-pregnant  state.  If  an  opportunity  of  examining  the  gravid 
wiQYWs  poHt-mortem  should  occur  at  this  time,  it  will  be  found  to  have 
the  form  of  a  ST">here  flattened  somewhat  posteriorly  and  l)ulging  ante- 
riorly. 

After  the  ascent  of  the  organ  into  the  abdomen  it  develops  more  in 
the  vertical  direction,  so  that  atjerm  it  has  the  form  of  an  ovoid,  with  its 
large  extremity  above  and  its  narrow  end  at  the  cervix  uteri,  and  its 
longitudinal  axis  corresponds  to  the  long  diameter  of  the  mother's  abdo- 
men, provided  the  presentation  be  either  of  the  head  or  breech.  The 
autcrioi-  surface  is  now  even  more  distinctly  projectino;  than  before — a 
fact  which  is  explained  by  the  proximity  of  the  posterior  surface  to  the 
rigid  spinal  column  behind — while  the  anterior  is  in  relation  with  the 
lax  abdominal  parietes,  which  yield  readily  to  pressure,  and  so  allow  of 
the  more  marked  jirominence  of  the  anterior  uterine  wall. 

Before  the  gravid  uterus  has  risen  out  of  the  pelvis  no  ap]>reciable 
increase  in  the  size  of  the  abdomen  is  perceptible.  1[  On  the  contrary,  it 
is  an  old  observation  that  at  this  early  state  of  pregnancy  the  abdomen 
is  flatter_jhan  jisiial,  on  account  of  the  partial  descent  of  the  uterus  in 
the  pelvic  ca^•ity  as  a  result  of  its  increased  weight,  j  As  the  growth  of 
the  (jrgan  advances  it  soon  becomes  too  large  to  be  contained  any  longer 


PREGNANCY. 


187 


within  the  pelvis,  and  about  tlie  middle  of  the  third  or  the  beginning 
of  the  fourtli  month  the  fundus  rises  above  the  pelvic  brim — not  sud- 
denly, as  is  often  erroneously  thought,  but  slowly  and  gradually — when 
it  may  be  felt  as  a  smooth  rounded  swelling. 

(it  is  about  this  time  that  the  movements  of  the  fjetus  first  become, 
appreciable  to  the  mother,  when  "  quickeithu/"  is  said  to  have  taken 
place.)  Toward  the  end  of  the  fourth  month  the  uterus  reaches  to 
about  three  fingers'  breadth  above  the  symphysis  pubis.  About  the 
fifth  month  it  occupies  the  hypogastric  region,  to  which  it  imparts  a 
marked  projection,  and  the  alteration  in  the  figure  is  uow  distinctly  per- 
ceptible to  visual  examination.  (About  the  sixth  month  it  is  on  a  level 
with,  or  a  little  above,  the  unTOilicusVFig.  73).     About  the  seventh 

Fig.  73. 


Relations  of  the  Pregnant  Uterus  at  Sixth  Month  to  the  Surrounding  Parts.    (After  Martin.) 

month  it  is  about  two  inches  above  the  umbilicus,  which  is  now  project- 
zing  and  prominent,  instead  of  depressed,  as  in  the  non-pregnant  state. 
(During  the  eighth  and  ninth  months  it  continues  to  increase  until  the 
summit  of  the  fundus  is  immediately  below  the  ensiform  cartilage/ 
(Fig.  74).  A  knowledge  of  the  size  of  the  uterine  tumor  at  various 
periods  of  pregnancy,  as  thus  indicated,  is  of  considerable  practical  im- 
portance, as  forming  the  only  guide  by  which  Aye  can  estimate  the  prob- 
able period  of  delivery  in  certain  cases  in  which  the  usual  data  for  cal- 


138 


PRKGNANCY. 


Fig.  74. 


filiation  aiv  al)S(_'nt  ;    as,  I'ur  L'\aiii[)l(',  wlicii  tlic  patient  lias  conceived 
(lurinLi:  lactation. 

e'ur  alx)iii  a  week  or  more  before  labor  the  uterus  {»;enerally  sinks  sonie- 
what  into  the  pelvic  cavity,  in  conse- 
quence of  the  relaxation  of  the  soft 
parts  which  precedes  delivery,  and  the 
])atient  now  feels  herself  smaller  and 
li<ihter  than  beforeJ  This  change  is 
familiar  to  all  ehilubearinir  women,  to 
wlu>m  it  is  known  as  "  the  lightening 
before  labor." 

AMiilc  the  uterus  remains  in  the  pel- 
vis its  loniiitudinal  axis  varies  in  direc- 
tion, nmeh  in  the  same  M'ay  as  that  of 
the  non-])rei;nant  uterus,  sometimes  be- 
ing more  or  less  vertical,  at  othei-s  in  a 
state  of  anteversion  or  partial  retrover- 
sion. These  variations  are  probably  de- 
pendent on  the  distension  or  em])tine&s 
of  the  Ijladder,  as  its  state  must  neces- 
sarily affect  the  })osition  of  the  movable 
organ  poised  behind  it.  After  the  uterus 
has  risen  into  the  abdomen  its  tendency 
is  to  project  forward  against  the  abdom- 
inal wall,  which  forms  its  chief  support 
in  front.  In  the  erect  position  the  long  axis  of  the  uterine  tumor  cor- 
resj)onds  with  the  axis  of  the  pelvic  brim,  forming  an  agle  of  about  'M)° 
with  the  horizon.)  In  the  semi-recumbent  ])Osition,  on  the  other  hand, 
as  Duncan^  has  pointed  out,  its  direction  becomes  much  more  nearly 
vertical.  In  women  who  have  borne  many  children  the  abdominal 
parietes  no  longer  afford  an  efficient  support,  and  the  uterus  is  displace*! 
anteriorly,  the  fundus  in  extreme  cases  even  hanging  downward. 

In  addition  to  this  anterior  oI)liquity,  on  account  of  the  projection  of 
the  spinal  column,  the  uterus  is  very  generally  also  displaced  laterally, 
and  sometimes  to  a  very  marked  degree,  so  that  it  ma}^  be  felt  entirely 
in  one  flank,  instead  of  in  the  centre  of  the  abdomen,  (in  a  large  pro- 
portion of  cases  this  lateral  deviation  is  to  tlie_  right  side,  and  many 
liypotheses  have  been  ])rought  forward  to  explain  this  fact,  none  of  them 
being  satisfactory.)  Thus,  it  has  been  supposed  to  dej)end  on  the  greater 
frequency  with  which  women  lie  on  their  right  side  during  sleep,  on  the 
greater  use  of  the  right  leg  during  walking,  on  the  supposed  comj)ai-a- 
tive  shortness  of  the  right  round  ligament  which  drags  the  tumor  to  that 
side,  or  on  the  frequent  distension  of  the  rectum  on  the  left  side,  which 
prevents  the  uterus  being  displaced  in  that  direction.  (Jf  these,  the  last 
is  the  cause  which  seems  most  constantly  in  ojieration,  and  most  likely 
to  produce  the  effect. 

The  cervix  must  obviously  adapt  itself  to  the  situation  of  the  body 
of  the  uterus.   (We  find,  therefore,  that  in  the  early  months,  when  the 


Size  of  Uterus  at  Various  Periods  of  Preg- 
nancy. 


uterus  lies  low  m  the  pelvis,  it  is  more  readily  Avithin  reach. 
'  Researches  in  Obstetrics,  p.  10- 


After  the 


PREGNANCY.  139 

ascent  of  tlic  uterus  it  is  dniwii  uj),  aiul  fVeqiieiitly  so  much  so  as  to  be 
reached  with  clillieulty.  When  tiie  uterus  is  uuich  antev(,'rte(l,  as  is  so 
often  tlic  case,  tiie  os  is  displaced  backward,  so  that  it  cannot  be  felt  at 
all  by  the  examining  finger. 

Toward  the  end  of  j)regnancy  the  greater  part  of  the  anterior  surface 
of  the  uterus  is  in  contact  with  the  abdominal  wall,  its  lower  ])ortion 
resting  on  the  posterior  surface  of  the  symphysis  jiubis.  I'he  posterior 
siu'face  rests  on  the  spinal  colunni,  while  the  small  intestines  are  j)ushed 
to  either  side,  the  large  intestines  surrounding  the  uterus  like  an  arch. 

Chang-es  in  the  Uterine  Parietes. — Tlie  great  distension  of  the 
uterus  during  pregnauey  was  formerly  supposed  to  be  mainly  due  to  the 
mechanical  pressure  of  the  enlarging  ovum  within  it.  If  this  were  so, 
then  the  uterine  walls  would  be  necessarily  much  thinner  than  in  the 
non-pregnant  state.  VTIus  is  well  known  not  to  be  the  case,  and  the 
immense  increase  in  the  size  of  the  uterine  cavity  is  to  be  explained 
by  the  hypertrophy  of  its  walls.)^  At  the  full  period  of  pregnancy  the 
thickness  of  the  uterine  parietes  is  generally  about  the  same  as  that  of 
the  non-pregnant  uterus,  rather  more  at  the  placental  site,  and  less  in 
the  neighborhood  of  the  cervix.j  Their  thickness,  however,  varies  in 
different  places,  and  in  some  women  they  are  so  thin  as  to  admit  of  the 
foetal  limbs  being  very  readily  made  out  by  palpation.  (Their  density 
is,  however,  always  much  diminished,  and,  instead  of  being  hard  and 
inelastic,  they  become  soft  and  yielding  to  pressure.N  This  cliange  coin- 
cides with  the  commencement  of  pregnancy,  of  whicn  it  forms,  as  recog- 
nizable in  the  cervix,  one  of  the  earliest  diagnostic  marks.  At  a  more 
advanced  period  it  is  of  value  as  admitting  a  certain  amount  of  yielding 
of  the  uterine  walls  to  movements  of  the  foetus,  thus  lessening  the 
chance  of  their  being  injured.  Bandl  has  pointed  out  that  during  the 
latter  months  of  pregnancy  the  lower  segment  of  the  uterus,  to  a  dis- 1 
tance  of  from  four  to  six  inches  above  the  inner  os,  is  thinner  and  less 
vascular  than  the  tissues  of  the  body  of  the  uterus  above.  This  thinner 
portion  is  separated  from  that  above  it  by  a  ridge,  often  easily  made 
out  when  the  hand  has  to  be  inserted  into  the  uterus  after  delivery, 
known  as  "  Bandl's  ring."  ^ 

Changes  in  the  Cervix  during-  Preg-nancy. — A^ery  erroneous  views 
have  long  been  taught,  in  most  of  our  standard  works  on  midwifery,  as 
to  the  changes  which  occur  in  the  cervix  uteri  during  pregnancy.  It 
is  generally  stated  that,  as  pregnancy  advances,  the  cervical  cavity  is 
greatly  diminished  in  length,  in  consequence  of  its  being  graduallv 
drawn  up  so  as  to  form  part  of  the  general  cavity  of  the  uterus,  so  that 
in  the  latter  months  it  no  longer  exists.  In  almost  all  midwifery  works 
accurate  diagrams  are  given  of  this  progressive  shortening  of  the  cervix 
(Figs.  75  to  78).  The  cervix  is  generally  described  as  having  lost  one- 
half  of  its  length  at  the  sixth  month,  two-thirds  at  the  seventh,  and  to 
be  entirely  obliterated  in  the  eighth  and  ninth.  The  correctness  of 
these  views  were  first  called  in  question  in  recent  times  by  Stoltz  in 
1826,  but  Dr.  Duncan,^  in  an  elaborate  historical  paper  on  the  subject, 

*  XJeher  das  Verhallen  des   Uterus  und  Cervix  in  der  Schtcangerschaft  und  ivakrend  der 
Ocbiirt,  1876. 
^  Researches  in  Obstetrics. 


14U 


riii:(;yAycy. 


lias  sliown  that  Stoltz  was  anticipated  hy  M'citlnvcli  in  1750,  and,  to  a 
less  (k'lrrc'c,  l)y  Kocdi-rci-  and  otlicr  writers.  Tliis  oijinion  is  now  i)r('tty 
gcnc'i-aily   adniittcil   to   be  eorreet,  and    is  nplield   by  Ca/eaux,  Arthur 


Fig.  7") 


Fig.  76. 


"    l^ 


Fig.  77. 


Fig.  7 


Supposed  Shortening  of  the  Cervix  at  the  Third,  .Sixth,  Eighth,  and  Ninth  Months  of  Preg- 
nancy, as  figured  in  obstetric  works. 

Farre,  Duncan,  and  most  modern  o])stetric'ians.  Indeed,  vanous  pod- 
moriem  examinations  in  advanced  pregnancy  have  shown  that(f he  cavity 
of  the  cervix  remains  in  reality  of"  its  normal  length  of  one  iuc-lA  and  it 

Fig.  79. 


Cervix  from  a  Wuman  dying  in  the  Eighth  Month  of  Pregnancy.    (,.\fier  Duncan.) 


PREGNANCY.  141 

can  often  be  measured  durini^lifeby  the  examining  finger  on  account  of  j 
its  patulous  state  (Fig.  70).  [During  the  fortm'glit  immediately  prcr-frl-  ' 
ing  delivery^  however,  a  rcalSshortening  or  oljlitoratioii  of  the  ccivii'ul 
cavity  takes  place,  eonnnencing  above,  until  the  cervical  canal  is  mei'ged 
into  the  uterine  cavity ;  but  this,  as  Duncan  has  ])ointed  out,  seems  to  I 
be  due  to  the  incipient  uterijie  contractions  which  prepare  the  cervix  ' 
for  laborN 

There  is,  no  doubt,  an  apparent  shortening  of  the  cervix  always  to  be 
detected  during  ])rcgnancy,  but  this  is  a  fallacious  and  deceptive  feeling, 
due  to  the  softness  of  the  tissue  of  the  cervix,  which  is  exceedingly 
characteristic  of  pregnan(y,  and  \vhich  to  an  experienced  finger  affords 
one  of  its  best  diagnostic  marks. 

In  the  non-pregnant  state  the  tissue  of  the  cervix  is  hard,  firm,  and 
inelastic.  (When  conception  occurs,  softening  begins  at  the  external  os, 
and  proceeds  gradually  and  slowly  upward  until  it  involves  the  whole 
of  the  cervix^  By  the  end  of  the  fourth  month  both  lips  of  the  os  are 
thick,  soft,  and  velvety  to  the  touch,  giving  a  sensation  likened  by 
Cazeaux  to  that  ]>roduced  by  pressing  on  a  table  through  a  thick,  soft 
cover.  By  the  sixth  month  at  least  one-half  of  the  cervix  is  thus 
altered,  and  by  the  eighth  the  whole  of  it ;  and  so  much  so  that  at  this 
time  those  unaccustomed  to  vaginal  examination  experience  some  dif- 
ficulty in  distinguishing  it  from  the  vaginal  walls,  (it  is  this  softening, 
then,  which  gives  rise  to  the  apparent  shortening  of  the  cervix  so  gen- 
erally described ;  and  it  is  an  invariable  concomitant  of  pregnancy, 
except  in  some  rare  cases  in  which  there  has  been  antecedent  morbid 
induration  and  hypertrophic  elongation  of  the  cervix.  (If,  therefore,  on  I 
examining  a  woman  supj)osed  to  l)c  advanced  in  pregnancy,  Ave  find 
the  cervix  to  be  hard  and  projecting  into  the  vaginal  canal,  we  may 
safely  conclude  that  jiregnancy  does  not  exist,  j  The  existence  of  soften- 
ing, however,  it  must  be  remembered,  will  noi  itself  justify  an  opposite 
conclusion,  as  it  may  be  produced,  to  a  very  considerable  extent,  by 
various  pathological  conditions  of  the  uterus. 

At  the  same  time  that  the  tissue  of  the  cervix  is  softened,  its  Ga.YJtyjs 
"\jiiilg.ned  and  the  external  os  becomes  patulous.  This  change  varies 
considerably  in  primiparte  and  multiparse.  In  the  former  the  external 
OS  often  remains  closed  until  the  encl  of  pregnancy ;  but  even  in  them 
it  generally  becomes  more  or  less  patulous  after  the  seventh  month,  and 
admits  the  ti])  of  the  examining  finger.  In  women  who  have  borne 
children  this  change  is  much  more  marked.  The  lips  of  the  external  os 
are  in  them  generally  fissured  and  irregular,  from  slight  lacerations  of 
its  tissue  in  former  labors.  It  is  also  sufficiently  open  to  admit  the  tip 
of  the  finger,  so  that  in  the  latter  months  of  pregnancv  it  is  often  quite 
possible  to  touch  the  membranes  and  through  them  to  feel  the  present- 
ing part  of  the  child. 

The  remarkable  incrense  jp  size  of  tl^p  uterus  during  pregnancy  is,  as 
we  have  seen,  chiefly  to  be  explained  by  the  growth  of  its  structures,  all 
of  which  are  modified  during  gestation.  The  ])eritoneal  covering  is  con- 
siderably increased,  so  as  still  to  form  a  complete  covering  to  t\\v  uterus 
when  at  its  largest  size.  William  Hunter  supposed  that  its  extension 
was  effected  rather  by  the  unfolding  of  the  layers  of  the  broad  ligament 


142  PREGXAycy. 

tliaii  l»y  i»n)\vtli.  Tliat  the  layers  of  the  l)roa<l  li<rament  do  iinfnld 
durinj^  gestation,  especially  in  the  early  months,  is  prohable  ;  hut  tiiis 
is  not  suffieient  to  account  for  the  complete  investment  of  the  ute- 
rus, and  it  is  certain  that  the  ])eritoii('um  grows  pari  pansu  with 
the  enlargement  of  the  uterus.  In  addition,  there  is  a  new  forma- 
tion of"  tihi'ous  tissue  between  the  ])eritoneal  and  the  museidar  coats, 
which  affords  strength  and  diminishes  the  risk  of  laceration  during 
labor. 

(The  hypertrophy  of  tlie^ms<'ular  tjssue  of  the  uterus  is,  however,  the 
most  remarkable  of  the  cliangcs  pi-(tduccd  by  j)regnaney.  Not  only  do 
the  pr<'vioiisly  cxi-ting  rndiiiieiitarv  fibre-cells  become  enormously 
increaM  il  in  >i/.( — >o  as  to  measure,  accordiu";  to  K(")llil<er,  from  seven 
to  eleven  times  their  foi-mer  length  and  from  two  to  five  times  their  for- 
mer breadth — but  uew  unstriped  fil)res  are  largely  develojK'd,  especially 
in  the  inner  layers.  )  These  new  cells  are  cliiefly  found  in  the  first 
months  of  pregnancy,  and  their  growth  seems  to  be  completed  by  the 
sixth  month.  The  connective  tissue  between  the  muscular  layers  is  also 
largely  increased  in  amount.  The  weight  of  the  muscular  tissue  of  the 
gravid  uterus  is  therefore  much  increased,  and  it  has  been  estimated  by 
Heschl  that  it  weighs  at  term  from  1  to  1.5  pounds;  that  is,  about  six- 
teen times  more  than  in  the  uuim])regnated  state.  This  great  develoj)- 
ment  of  the  muscular  tissue  admits  of  its  dissection  in  a  way  which  is 
quite  impossible  in  the  unimpregnated  state,  and  the  researches  of  Helie 
(]).  61)  enable  us  to  understand  much  better  than  before  how  the  mus- 
cles forming  the  walls  of  the  gravid  uterus  act  during  the  expulsion  of 
the  child. 

The  changes  in  the  mucous  coat  of  the  uterus  which  result  in  the  for- 
mation of  the  decidua,  have  already  been  discussed  at  length  elsewhere 
(p.  101). 

The  circii  1  atorv  a]-)])arat us  of  the  uterus  during  ])regnancy  has  been 
described  when  the  anatomy  of  the   j)lacenta  was  under  consideration 

The  lym])haties  are  nnich  increased  in  size ;  and  recent  theories  on  the 
production  of  certain  })uerperal  diseases  attribute  to  them  a  more 
important  action  than  has  been  commonly  assigned  to  them. 

The  fjuestion  of  the  growth  of  the  nerves*  has  been  hotly  discussed. 
Robert  Lee  took  the  foremost  place  among  those  Mho  maintained  that 
the  nerves  of  the  uterus  share  tlie  general  growth  of  its  other  constitu- 
ent parts./"  Dr.  Snow  Beck,  however,  believed  that  they  remain  of  the 
same  size 'as  in  the  unimpregnated  state,  and  this  view  is  su]iported  by 
Hirschield,  Robin,  and  other  recent  MritersA  Robin  thought  that  there 
is  an  apparent  increase  in  the  size  of  the  niM-ve-tubcs,  which,  however, 
is  really  due  to  increase  in  the  neurilemma.  Kilian  describes  the  nei'ves 
as  increasing  in  length,  but  not  in  thickness,  while  Schroeder  states  that 
they  })articij)ate  equally  with  the  lymphatics  in  the  enlargement  the  lat- 
ter undergo,  f  Whichever  of  these  views  may  ultimately  be  found  to  be 
correct,  it  is  certain  that  analogy  would  lead  us  to  expect  an  increase  of 
nervous  as  well  as  of  vascular  su])j)ly.  j 

General  Modifications  in  the  Body  produced  by  Preg-nancy. — It 
ife  not  in  the  uterus  alone  that  pregnancy  is  found  to  produce  moditica- 


PREGNANCY.  143 

tions  of  iiiij)oi'tanec.  (There  are  few  of  the  more  important  functions  of 
the  hotly  wliich  are  not,  to  a  g-ieater  or  less  extent,  aifected\  to  some  of 
these  it  is  necessary  l)riefly  to  direct  attention,  inasnuich  as,  Aviien  carried 
to  excess,  thev  produce  those  disorders  which  often  complicate  gestation, 
and  which  prove  so  distressing  and  even  dangerous  to  the  patients.  Such 
of  them  as  are  apparent  and  may  aid  us  in  diagnosis  are  discussed  in  the 
chapter  which  treats  of  the  signs  and  symptoms  of  pregnancy :  in  this  o< 

jilace  it  is  only  necessary  to  refer  to  those  which  do  not  properly  fall  (i 

into  that  category.  •  y 

/Amongst  those  wliich  are  most  constant  and  important  are  the  altera-    ,  / 

tibns  in  the  comimsition  of  the  blood?)    The  opinion  of  the  profession  ^^ 

on  this  subject  has  of  late  years  undergone  a  remarkable  change.^  ^^  ,\ 
Formerly,  it  was  universally  believed  that  pregnancy  was,  as  the  rule,  ^^  i'^ 
associated  with  a  condition  analogous  to  plethora,  and  that  this  ex- 
plained  many  characteristic  phenomena  of  common  occurrence,  such  as 
headache,  j)alpitation,  singing  in  the  ears,  shortness  of  breath,  and  the 
like.  As  a  consequence,  it  was  the  habitual  custom — not  yet  by  any 
means  entirely  abandoned — to  treat  pregnant  women  on  an  antiphlo- 
gistic system,  to  place  them  on  low  diet,  to  administer  lowering  reme- 
dies, and  very  often  to  practise  venesection,  sometimes  to  a  surprising 
extent.  Thus  it  was  by  no  means  rare  for  women  to  be  bled  six  or 
eight  times  during  the  latter  months,  even  when  no  definite  symptoms 
of  disease  existed ;  and  many  of  the  older  authors  record  cases  .where 
depletion  was  practised  every  fortnight  as  a  matter  of  routine,  and, 
when  the  symptoms  were  well  marked,  even  from  fifty  to  ninety 
times  in  the  course  of  a  single  pregnancy. 

Composition  of  the  Blood  in  Pregnancy. — Numerous  careful 
analyses  have  conclusively  proved  that  the  composition  of  the  blood 
during  pregnancy  is  very  generally — perhaps  it  would  not  be  too  nuich 
to  say  always — profoimdly  altered.  "OThus  it  is  found  to  be  more  watery, 
its  serum  is_deficient  in  albumen,  ancithe  amount  of  colored  globules 
is  materially  diminished,  averaging,  according  to  the  analysis  of  Bec- 
querel  and  Rodier,  111.8  against  127.2  in  the  non-gravid  state.  ^At 
the  same  time,  the  amount  of  fibrin  and  of  extractive  matter  is  consid- 
eral)ly  increased.  )  The  latfer~observation  is  of  peculiar  importance,  and 
it  goes  far  to  explain  the  frequency  of  certain  thrombotic  affections  ob- 
served in  connection  with  pregnancy  and  delivery :  this  hyperinosis  of 
the  blood  is  also  considerably  increased  after  labor  by  the  quantity  of 
effete  material  thrown  into  the  mother's  system  at  that  time,  to  be  got 
rid  of  by  her  emunctories.  The  truth  is,  that  the  blood  of  the  preg- 
nant woman  is  generally  in  a  state  much  more  nearly  approaching  the 
condition  of  ansemia  than  of  plethora,  and  it  is  certain  that  most  of  the 
phenomena  attributed  to  plethora  may  be  explained  equally  Avell  and 
better  on  this  view.  These  changes  are  much  more  strongly  marked  at 
the  latter  end  of  pregnancy  than  at  its  connnencement,  and  it  is  inter- 
esting to  observe  that  it  is  then  that  the  concomitant  phenomena  alluded 
to  are  most  frequently  met  with.  Cazeaux,  to  whom  we  are  chiefly 
indebted  for  insisting  on  the  practical  bearing  of  these  views,  contends 
that  the  pregnant  state  is  essentially  analogous  to  chlorosis,  and  that  it 
should  be  so  treated.     More  recently,  the  accurate  observations  of  AVill- 


144  PREGl^ANCY. 

cocks  ^  have  shown  that  tlie  blood  of  pregnancy  differs  from  that  of 
chlorosis  in  the  fact  that  while  in  both  tlie  amount  of  luemoglobin  is 
lessened,  in  pregnancy  the  individual  blood-cells  are  not  impoverished 
as  they  are  in  chlorosis,  but  sim})ly  lessened  in  comparative  number, 
owing  to  an  increase  in  the  water  of  the  j)lasma,  due  to  the  progressive 
enlargement  of  the  vascular  area  during  gestation.  Objection  has  not 
unnaturally  been  taken  to  Cazeaux's  theory,  as  implying  that  a  healthy 
and  normal  function  is  associated  with  a  morbid  state ;  and  it  has  been 
suggested  that  this  deteriorated  state  of  the  blood  may  be  a  wise  pro- 
vision of  nature  instituted  for  a  purpose  we  are  not  as  yet  al)le  to  under- 
stand. It  may  certainly  be  admitted  that  i)regnancy,  in  a  perfectly 
healthy  state  of  the  system,  slnjuld  not  be  associated  with  phenomena 
in  themselves  in  any  degree  morbid.  It  must  not  be  forgotten,  how- 
ever, that  our  patients  are  seldom — we  might  safely  say  never — in  a 
state  that  is  physiologically  healtliy.  The  influence  of  civilization, 
climate,  occupation,  diet,  and  a  thousand  other  disturbing  causes  that, 
to  a  greater  or  less  degree,  are  always  to  be  met  with,  must  not  be  left 
out  of  consideration.  Making  every  alkmance,  therefore,  for  the  un- 
doubted fact  that  pregnancy  ought  to  be  a  perfectly  healthy  condition, 
it  must  be  conceded,  I  think,  that  in  the  vast  majority  of  cases  coming 
under  our  notice  it  is  not  entirely  so  ;  and  the  deductions  drawn  by 
Cazeaux  from  the  numerous  analyses  of  the  blood  of  pregnant  women 
seem  to  point  strongly  to  the  conclusion  that  the  general  blood-state  is 
tending  to  poverty  and  anaemia,  and  that  a  depressing  and  antiphlo- 
gistic treatment  is  distinctly  contraindicated. 

Modifications  in  Certain  Viscera. — Closely  connected  with  the 
altered  condition  of  the  blood  is  the  physiological  ^\YP'iil''^''^'P*'y  ftf  till' 
li^art,  which  is  now  well  known  to  occur  during  jjregnancy.  This  was 
first  pointed  out  by  Larcher  in  182(S,  and  it  has  been  since  verified  by 
numerous  observers.  It  seems  to  be  constant  and  considerable,  and  to 
be  a  purely  physiological  alteration  intended  to  meet  the  increased  exig- 
encies of  the  circulation  which  the  complex  vascular  arrangements  of 
the  gravid  uterus  produce.  The  hypertrophy  is  limited  to  the  left 
ventricle,  the  right  ventricle,  as  well  as  both  auricles,  being  unaffected. 
Blot  estimates  that  the  whole  weight  of  the  heart  increases  one-fifth 
during  gestation.  The  more  recent  researches  of  Lohlein  '  render  it 
probable  that  the  hypertrophy  is  less  than  those  authors  have  supposed. 
According  to  Duroziez,^  the  heart  remains  enlarged  during  lactation,  but 
diminishes  in  size  immediately  after  delivery  in  women  who  do  not 
suckle,  while  in  women  who  have  l)orne  many  children  it  remains  per- 
manently somewhat  larger  than  in  nulliiiane.  Similar  increase  in  the 
size  of  other  organs  has  been  pointed  out  1)V  various  Avriters ;  as,  for 
example,  in  the  lymphatics,  the  spleen,  and  the  liver.  Tarnier  states 
that  in  women  who  have  died  after  delivery  the  organs  always  show 
signs  of  fatty  degeneration.     According  to  Gassncr,  the  whole  body 

'  "  Comparative  Observations  on  the  Blood  in  Clilorosis  and  Pregnancv,"  by  Fred. 
Willcock-s,  IM.  D. :   The  Lancet,  December  3,  1881. 

'  Zeihchrift  fur  Geburtxliillfe  inul  Gyncik.,  1876,  Bd.  i.  S.  482:  "Ueber  das  Verhalten 
des  Herzens  bei  Sclnvangerin  u.  AVochnerinnen." 

3  Gaz.  des  H6pit.,  1868. 


PREGNANCY.  145 

increases  in  weight  (luring:  the  hittcsr  months  of  pregnancy,  and  this 
increase  is  somewhat  beyond  that  which  can  be  explained  by  the  size  of 
the  womb  and  its  contents. 

Formation  of  Osteophytes. — Irregular  bony  deposits  between  the 
.skull  and  the  dura  mater,  in  some  cases  so  largely  developed  as  to  line 
the  whole  cranium,  have  been  so  frequently  detected  in  women  who 
have  died  during  parturition  that  they  are  believed  by  .some  to  be  a  nor- 
mal production  connected  with  pregnancy.  Ducrest  found  these  osteo- 
])iiytes  in  more  than  one-third  of  the  cases  in  which  he  performed  post- 
mortem examinations  during  the  puerperal  period.  Rokitan.sky,  who 
corroborated  the  observation,  believed  this  peculiar  deposit  of  bony 
matter  to  be  a  physiological,  and  not  a  pathological,  condition  connected 
with  pregnancy ;  but  whether  it  be  so,  or  how  it  is  produced,  has  not 
yet  been  satisfactorily  determined. 

Chang'es  in  the  Nervous  System. — More  or  less  marked  changes 
connected  with  the  nervous  system  are  generally  observed  in  pregnancy^ 
and  sometimes  to  a  very  great  extent.  When  carried  to  excess  they 
produce  some  of  the  most  troublesome  disorders  which  complicate  gesta- 
tion, such  as  alterations  in  the  intellectual  functions,  changes  in  the  dis- 
position and  cliaracter,  morbid  cravings,  dizziness,  neuralgia,  syncope,, 
and  many  others.  They  are  purely  functional  in  their  character,  and 
disappear  rapidly  after  delivery,  and  may  be  best  described  in  connection 
with  the  disorders  of  pregnancy. 

Changes  in  the  Respiratory  Organs. — Respiration  is  often  inter- 
fered with,  from  the  mechanical  results  of  the  pressure  of  the  enlarged 
uterus.  The  longitudinal  dimensions  of  the  thorax  are  lessened  by  the 
upward  displacement  of  the  diaphragm,  and  this  necessarily  leads  to 
sQme  embarrassment  of  the  respiration,  which  is,  however,  compensated 
to  a  great  extent  by  an  increase  in  breadth  of  the  base  of  the  thoracic 
cavity. 

Changes  in  the  Liver. — The  liver  has  been  observed  to  show  cer- 
tain changes  in  pregnancy.  Numerous  small  yellow  spots  are  seen 
scattered  through  its  substance,  varying  in  size  from  a  pin's  head  to  a 
millet-seed  ;  and  these  are  produced  l)y  tatty  dt  pusiis  in.  the  hepatic  cells, 
which  De  Sinety  believes  to  be  associated  mainly  with  lactation  and  to 
disaj)pear  when  that  is  concluded. 

Changes  in  the  Urine. — Certain  changes,  which  are  of  very  constant 
occurrence,  in  the  urine  of  pregnant  women  have  attracted  much  atten- 
tion, and  have  been  considered  by  many  writers  to  be  pathognomonic. 
'J'hey  consist  in  the  presence  of  a  peculiar  deposit,  formed  when  the 
urine  has  been  allowed  to  stand  for  some  time,  which  has  received  the 
name  of  kicsfehi.  Its  jiresence  was  known  to  the  ancients,  and  it  was 
particularly  mentioned  by  Savonarola  in  the  fifteenth  century,  but  it  has 
more  especially  been  studied  within  the  last  thirty  years  by  Eguisier, 
Golding  Bird,  and  others.  If  the  urine  of  a  pregnant  woman  be' 
allowed  to  .stand  in  a  cylindrical  vessel,  exposed  to  light  and  air,  but 
protected  from  dust,  in  a  jieriod  varying  from  two  to  seven  davs  a  pecu- 
liar flocculent  sediment,  like  fine  cotton-wool,  makes  its  appearance  in 
the  centre  of  the  fluid,  and  soon  afterward  rises  to  the  surface  and  forms 
a  pellicle,  which  has  been  compared  to  the  fat  of  cx)ld  mutton-broth.  In 

10 


146  rni:r;xAycr. 

the  course  of"  a  few  days  the  sciim  hicaUs  iij)  and  falls  to  the  bottom  of 
the  vessel.  On  niieroseopic  examination  it  is  lound  to  be  eomj)osed  <jf 
fat-part iclrs,  wlili  (  lystals  of  ammoniaco-maj^nesium  |)hosj)]uites  and 
phosphate  of  lime,  and  a  large  fpiantit\'  of  vilu-iones.  These  aj)pearanees 
are  generally  to  be  detected  alter  tin  ~<(nii(|  month  of  pregnancy,  and 
up  to  the  seventh  oi- eighth  montli,  afier  which  they  are  rarely  j)ro<lurcd. 
l\egnauld  exj>lains  tiicir  al)sence  during  the  latter  months  of  gestation 
by  the  presence  iu  the  urine  at  that  time  of  free  lactic  acid,  uhich 
increases  its  acidity  and  prevents  the  decomposition  of  the  urea  into  car- 
bonate of  ammonia.  He  believes  that  kiestein  is  ])roduced  by  the  action 
of  free  carbonate  of  annnonia  on  the  phosj)hate  of  lime  contained  in  the 
urine,  and  that  this  reaction  is  })reventcd  by  the  excess  of  acid. 

Golding  Jiii'd  believed  kiestein  to  be  analogous  to  casein,  to  tlie  pres- 
ence of  •which  he  referred  it,  and  he  states  that  he  has  ibund  it  in 
27  out  of  30  cases.  Braxton  Hicks  so  far  corroborates  liis  view, 
and  states  that  the  dej^osit  of  kiestein  can  be  much  more  abundantly 
produced  if  one  or  tMO  teaspoonfuls  of  rennet  be  added  to  the  urine, 
since  that  substance  has  the  property  of  coagulating  casein.  Much  less 
importance,  however,  is  now  attached  to  the  presence  of  kiestein  than 
formerly,  since  a  precisely  similar  substance  is  sometimes  found  in  the 
urine  of  the  non-pregnant,  especially  in  antemic  women,  and  even  in  the 
urine  of  men.  Parkes  states  that  it  is  not  of  uniform  composition,  that 
it  is  produced  by  the  decom])osition  of  urea,  and  consists  of  the  free 
phosphates,  bladder-nuicus,  infusoria,  and  vaginal  discharges.  Neuge- 
bauer  and  Vogel  give  a  similar  account  of  it,  and  hold  that  it  is  of  no 
diagnostic  value.  That  it  is  of  interest  as  indicating  the  changes  going 
on  in  connection  with  pregnancy  is  certain ;  but  inasmuch  as  it  is  not 
of  invariable  occurrence,  and  may  even  exist  quite  independently  of 
gestation,  it  is  obviously  quite  undeserving  of  the  extreme  importance 
that  has  been  attached  to  it. 

Toward  the  end  of  pregnancy  sugar  may  sometimes  be  detected  in  the 
urine,  and  after  delivery  and  during  lactation  it  exists  in  considerable 
abundance;  thus  out  of  35  cases  tested  in  the  Simpson  Memorial  Hos- 
pital in  Edinburgh  during  the  puerperium,  it  was  found  in  all,  the 
amount  varying  from  1  to  8  per  cent.'  Kalten1)ach  has  shown  that  this 
temporary  glycosuria  is  due  to  the  jiresence  of  milk-sugar  in  the  urine, 
and  that  it  ceases  with  the  disappearance  of  milk  from  the  breasts.- 
This  ])hysiological  glycosuria  nuist  be  carefully  distinguished  from  true 
diabetes,  which  is  a  grave  complication  of  pregnancy. 

Albumen  is  often  present  during  the  latei*  stages  of  ])regnancy,  and  it 
may  be  transitory  and  of  eom])aratively  little  moment,  although  its 
j)resence  must  always  be  a  cause  of  some  anxiety.  Leyden  bi-lieves  that 
it  is  most  often  met  with  in  the  second  half  of  a  frsf  ])regnancy,  and  it 
may  become  chronic,  leading  to  granular  atro])hy  of  the  kidneys,'*  In 
some  cases  it  seems  to  be  the  result  of  catarrhal  conditions  of  the  blad- 
der ;  in  others  it  is  probably  caused  by  undue  arterial  tension  consequent 
on  pregnancy. 

'  Eflin.  Med.  Journ.,  vol.  1881-82,  p.  116. 

^  Zrii.f.  Gebnrl.  n.  Gijn.,  1879,  Bd.  iv.  S.  101  :  "  Die  Lactosurie  der  Wodinerinnen." 

'  Deutsche  vied.  Wocheusch.,  1886,  Iso.  9. 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  147 


CHAPTER  IV. 

SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

In  attemptiug  to  ascertain  the  presence  or  absence  of  pregnancy 
tlic  pi-actitioner  has  before  liim  a  problem  which  is  often  beset  with 
great  difficulties,  and  on  the  proper  solution  of  which  the  moral  charac- 
ter of  his  patient,  as  well  as  his  own  professional  reputation,  may 
depend.  The  patient  and  her  friends  can  hardly  be  expected  to  appre- 
ciate the  fact  that  it  is  often  far  from  easy  to  give  a  positive  opinion  on 
the  point  -,  and  it  is  always  advisable  to  use  much  caution  in  the  exam- 
ination, and  not  to  commit  ourselves  to  a  positive  opinion  except  on  the 
most  certain  grounds.  This  is  all  the  more  important  because  it  is  just 
in  those  cases  in  which  our  opinion  is  most  frequently  asked  that  the 
statements  of  the  patient  are  of  least  value,  as  she  is  either  anxious  to 
conceal  the  existence  of  pregnancy,  or,  if  desirous  of  an  affirmative 
diagnosis,  unconsciously  colors  her  statements  so  as  to  bias  the  judg- 
ment of  the  examiner. 

Constant  attempts  have  been  made  to  classify  the  signs  of  pregnancy; 
thus,  some  divide  them  into  the  natural  and  sensible  signs,  others  into 
the  presumptive,  the  probable,  and  the  certain.  The  latter  classification, 
which  is  that  adopted  by  Montgomery  in  his  classical  work  on  the 
Signs  and  Symptoms  of  Pregnancy,  is  no  doubt  the  better  of  the  two, 
if  any  be  required.  The  simplest  Avay  of  studying  the  subject,  how- 
ever, is  the  one,  now  generally  adopted,  of  considering  the  signs  of 
pregnancy  in  the  order  in  which  they  occur,  and  attaching  to  each  an 
estimate  of  its  diagnostic  value. 

Signs  of  a  Fruitful  Conception. — From  the  earliest  ages  authors 
have  thought  that  the  occurrence  of  conception  might  be  ascertained  by 
certain  obscure  signs,  such  as  a  peculiar  appearance  of  the  eyes,  swelling 
of  the  neck,  or  by  unusual  sensations  connected  with  a  fruitful  inter- 
course. All  of  these,  it  need  hardly  be  said,  are  far  too  uncertain  to  be 
of  the  slightest  value.  The  last  is  a  symptom  on  which  many  married 
women  profess  themselves  able  to  depend,  and  one  to  which  Cazeaux  is 
inclined  to  attach  some  importance. 

Cessation  of  Menstruation. — The  first  appreciable  indication  of 
])rc'gnancy  on  which  any  dependence  can  be  placed  is  the  cessation  of 
the  ciistDiuMry  inriistrual  discharge;  and  it  is  of  great  importance,  as 
loniiiiiw-  the  (iiily  ivliablc  guide  for  calculating  the  probable  period  of 
delivery.  In  women  mIio  have  been  ])reviously  iierfectlv  regular,  in 
whom  there  is  no  morbid  cause  which  is  likely  to  have  produced  sup- 
pression, the  non-appearance  of  the  catamenia  may  be  taken  as  strong 
presumptive  evidence  of  the  existence  of  j^regnancy ;  but  it  can  never 
be  more  than  this,  unless  verified  and  strengthened  by  other  signs, 
niasmuchias  there  are  many  conditions  besides  pregnancy  which  may 
lead  to  its  non-appearance.     Thus,  exposiirc  jo  _cold,  meutal_gjiiption, 


148  PREayANCY. 

general  debility,  especially  \vlien  coiineeted  with  iiiei])ieiil  plitluj^is,  may 
all  Have  this  etteet.  Mental  imjires'^ionsarepeeiiliarly  liable  to  mislead 
in  this  respect.  It  is  far  from  uncommon  in  newly-married  women  to 
find  that  menstruation  ceases  for  one  or  more  ])eri<»ds,  either  from  the 
general  disturbance  of  the  system  connected  with  the  married  life  or 
from  a  desire  on  the  part  of  the  patient  to  find  herself  jn-egnant.  Also 
in  unmarried  women  who  have  subjected  themselves  to  the  risk  of 
impregnation  mental  emotion  and  alarm  often  ])roduce  the  same 
rcj^uit. 

\A.  further  source  of  uncertainty  exists  in  the  fact  that  in  certain  ("ases 
menstruation  may  go  on  for  one  or  more  periods  after  conccptioji  or 
even  diu'ing  tiie  whole  picLinancy.  ]  The  latter  occurrence  is  certainly 
of  extreme  rarity,  but  one  or  two  instances  are  recorded  by  Perfect, 
Churchill,  and  other  writers  of  authority,  and  therefore  its  })ossibility 
must  be  admitted.  The  former  is  much  less  uncommon,  and  instances 
of  it  have  probably  come  under  the  observation  of  most  practitioners. 
The  explanation  is  now  well  understood. (  During  the  early  months  of 
gestation,  when  the  ovum  is  not  yet  sufficiently  advanced  in  growth  to 
fill  tlie  whole  uterine  cavity,  there  is  a  considerable  space  between  the 
decidua  reflexa  which  surrounds  it  and  the  decidua  vera  lining  the  ute- 
\  rine  cavity.  )  It  is  from  this  free  surface  of  the  decidua  vera  that  the 
periodical  discharge  comes,  and  there  is  not  only  ample  surface  for  it  to 
come  from,  but  a  free  channel  for  its  esca})e  through  the  os  uteri.  After 
the  third  month  the  decidua  reflexa  and  the  decidua  vera  blend  together 
and  the  space  between  them  disappears.  Menstruation  after  this  time 
is,  therefore,  much  more  difficult  to  account  for.  It  is  probable  that  in 
many  supposed  cases  occasional  losses  of  blood  from  other  sources,  such 
as  placenta  prsevia,  an  aljradcd  cervix  uteri,  or  a  small  polypus,  have 
been  mistaken  for  true  menstruation.  If  the  discharge  really  occurs 
periodically  after  the  third  month,  it  can  only  come  from  the  canal  of 
the  cervix.  The.  occurrence,  however,  is  so  rare  that  if  a  woman  is 
menstruating  regularly  and  normally  who  believes  herself  to  be  more 
than  four  months  advanced  in  pregnancy,  we  ai'e  justified  ipso  fad o  in 
negativing  her  su])position.  (  [Menstruation  in  a  pregnant  woman  may 
be  due  to  the  existence  of  a  double  uteiiLr;,  one  half  of  which  is  emj)ty 
and  free,  while  the  other  contains  a  fnetus.  Th^wo  halves  or  compart- 
ments may  be  impregnated  at  dift'erent  jiei^^,  and  give  rise  to  a 
so-called  superfnetation. — Ed.]  )  In  an  uninarried  woman  all  state- 
ments as  to  regularity  of  menstruation  are  absolutely  valueless,  for  in 
such  cases  nothing  is  more  common  than  for  the  patient  to  make  false 
statements  for  the  express  pur])ose  of  dece])tion. 
(  Conceptioii  may  nnfjuestipnably  occur  when  menstruation  is  nor- 
nTallj_al)sent.  \  This  is  far  from  uncommon  in  women  during  TactathmT- 
wEen  the  function  is  in  abeyance,  and  who  therefore  have  no  reliable 
(lata  for  calculating  the  true  period  of  their  delivery.  Authentic  cases 
are  also  recoi-ded  in  Avhich  young  girls  have  conceived  before  menstrua- 
tion is  established,  and  in  which  pregnancy  has  occurred  after  the  change 
of  life. 

Taking  all  these  facts  into  account,  we  can  only  look  upon  the  cessa- 
tion  of  menstruation   as  a  fairly  presumptive  sign  of  pregnancy  in 


SIGNS  AND  SYMPTOMS  OF  PRFMNANCY.  149 

woiiun  in  ulioiii  there  is  no  clear  reason  to  account  for  it,  hut  one  which 
is  undoubtedly  of  great  value  in  assisting  our  diagnosis. 

Shortly  after  concej)tion  various  sympathetic  disturbances  of  the  sys- 
tem occur,  and  it  is  only  very  exceptionally  that  these  are  not  estab- 
lished. They  are  generally  most  developed  in  women  of  highly  ner- 
vous temperament ;  and  they  are  therefore  most  marked  in  patients  in 
the  upper  classes  of  society,  in  whom  this  class  of  organization  is  most 
common. 

Morning-  Sickness. — Amongst  the  most  frequent  of  these  are  various 
disorders  of  the  gastro-intestinal  canal.  Nausea  or  vomiting  is  very 
common  ;  and  as  it  is  generally  felt  on  first  rising  from  the  recumbent 
position,  it  is  popularly  known  amongst  women  as  the  "  morning  sick- 
ness."/It  sometimes  commences  almost  immediately  after  conception, 
but  more  frequently  not  until  the  srcund  month,  and  it  rarely  lasts  after  > 
the  fourth  mouth)  Generally  there  is  nausea  rather  than  actual  vomit- 
ing. The  Avoma'n  feels  sick  and  unable  to  eat  her  breakfast,  and  often 
brings  up  some  glairy  fluid.  In  other  cases  she  actually  vomits  ;  and 
sometimes  the  sickness  is  so  excessive  as  to  resist  all  treatment,  seriously 
to  affect  the  patient's  health,  and  even  imperil  her  life.  These  grave 
forms  of  the  affection  will  require  separate  consideration. 

Very  different  opinions  have  beeu  held  as  to  the  cause  of  morning 
sickness.  Dr.  Henry  Bennet  believes  that,  when  at  all  severe,  it  is 
always  associated  with  congestion  and  inflammation  of  the  cervix  uteri. 
Dr.  Graily  Hewitt  maintains  that  it  depends  entirely  on  the  flexion  of 
the  uterus,  producing  irritation  of  the  uterine  nerves  at  the  seat  of  the 
flexion,  and  consequent  sympathetic  vomiting.  This  theory,  when 
broached  at  the  Obstetrical  Society,  was  received  with  little  favor :  it 
seems  to  me  to  be  stifficiently  disproved  by  the  fact,  which  I  believe  to 
be  certain,  that  more  or  less  nausea  is  a  normal  and  nearly  constant 
phenomenon  in  pregnancy,  for  it  is  difficult  to  believe  that  nearly  every 
pregnant  woman  has  a  flexed  uterus.  U^'he  generally  received  explana- 
tion is  probably  the  correct  one — viz.  that  nausea  as  well  as  other  forms 
of  sympa.thetic  disturba,nce  depends  on  the  stretching  of  the  uterine 


fibres  by  the  growing  ovum,  and  consequent  irritation  of  the  uterine 
nerves.  It  is  therefore  nwv,  and  only  one,  of  the  numerous  reflex  phe- 
nomena naturally  accompanying  pregnancy.  \  It  is  an  old  observation 
that  when  the  sickness  of  pregnancy  is  entirely  absent,  other  (and  gen- 
erally more  distressing)  sympathetic  derangements  are  often  met  with, 
such  as  a  tendency  to  syncope.  Dr.  Bedford^  has  laid  especial  stress  on 
this  point,  and  maintains  that  under  such  circumstances  women  are 
peculiarly  apt  to  miscarry. 

Other  derangements  of  the  digestive  functions,  depending  on  the 
same  cause,  are  not  uncommon,  such  as  excessive  or  depraved  appetite, 
the  patient  showing  a  craving  for  strange  and  even  disgusting  articles 
of  diet.  These  cravings  may  be  altogether  irresistible,  and  are  popu- 
larly known  as  "  longings."  Of  a  similar  character  is  the  disturbed 
condition  of  the  bowels  frequently  observed,  leading  to  constipation, 
diarrhrfa,  and  excessive  flatulence. 

Certain  glandular  sym])athies  may  be  developed,  one  of  the  most 

^  Diseases  of  Women  and  Children,  p.  551. 


150  PREOyA^X'Y. 

(.'oiuuiuii  bciii^  an  excessive  secretion  J  roin  the  .salivaiygltim^'^-  A  tend- 
ency to  syncope  is  not  uufrefjuent,  rarely  proceeding  to  actual  fainting, 
but  rather  to  that  sort  of  jiartial  syncope,  unattended  with  complete  loss 
of  consciousness,  which  the  older  auth<»rs  used  to  call  '^  lypotheniia." 
This  often  occurs  in  women  wiio  show  no  such  tendency  at  other  times, 
and,  when  developed  to  any  extent,  it  forms  a  very  distressing  accom- 
paniment of  pregnancy.  Toothache  is  common,  and  is  not  rarely  asso- 
ciated with  actual  caries  of  the  teeth.  When  any  of  these  j)henomena 
are  carried  to  excess,  it  is  more  than  probable  that  some  morbid  condi- 
tion of  the  uterus  exists,  whicii  increases  the  local  irritation  producing 
them. 

Mental  Peculiarities. — Mental  phenomena  are  very  general.  An 
undue  degree  of  despondency,  utterly  beyond  the  patient's  control,  is 
far  from  uncommon  ;  or  a  change  which  rendcre  the  bright  and  good- 
tempered  woman  fractious  and  irritable  ;  or  even  the  more  fortunate, 
but  less  common,  change  by  which  a  disagreeable  disposition  becomes 
\  altered  lor  the  better. 

All  these  ])henomena  of  exalted  nervous  susceptibility  are  of  but 
slight  diagnostic  value.  Thev  mav  be  taken  as  corroborating  more  cer- 
tain  signs,  but  nothing  more  ;  and  they  are  chiefly  interesting  from  their 
tendency  to  be  carried  to  excess  and  to  produce  serious  disorders. 

Mammary  Changes. — Certain  changes  in  the  manuuje  are  of  early 
occurrence,  dependent,  no  doubt,  on  the  intimate  sympathetic  relations 
at  all  times  existing  between  them  and  the  uterine  organs,  but  chiefly 
required  for  the  purpose  of  preparing  for  the  im])oi"tant  function  of 
lactation  which  on  the  termination  of  pregnancy  they  have  to  per- 
form. 

Generally  about  the  second  month  of  pregnancy  the  breasts  become 
mcreased  in  size  and  tender.  As  pregnancy  advances  they  become 
much  larger  and  firmer,  and  blue  veins  may  be  seen  coursing  over  them. 
The  most  characteristic  changes  are  about  the  nip])les  and  areola?.  The 
nipples  become  turgid,  and  are  frequently  covered  with  minute  branny 
scales,  formed  by  the  desiccation  of  sero-lactescent  fluid  oozing  from 
them.  The  areolae  become  greatly  enlarged  and  dai'kened  from  the 
deposit  of  pigment  (Fig.  80).  The  extent  and  degree  of  this  discol- 
oration vary  nuich  in  different  women.  In  fair  women  it  may  i)e  so 
slight  as  to  be  hardly  a]iprceiable ;  while  in  dark  women  it  is  generally 
exceedingly  characteristic,  sometimes  forming  a  nearly  black  circle 
extending  over  a  great  part  of  the  breast.  The  areola  becomes  moist 
as  well  as  dark  in  appearance,  and  is  somewhat  swollen,  and  a  nund)er 
of  small  tubercles  are  developed  upon  it,  forming  a  circle  of  projections 
round  the  nip])le.  These  tubercles  are  descriljcd  1)V  Montgomery  as 
being  intimately  connected  with  the  lactiferous  ducts,  some  of  which 
may  occasionally  be  traced  into  them  and  seen  to  open  on  their  sum- 
mits. As  pregnancy  advances  they  increase  in  size  and  number.  During 
the  latter  months  what  has  been  called  "  the  secondary  areola  "  is  jiro- 
duced,  and  when  well  marked  presents  a  very  characteristic  appearance. 
It  consists  of  a  number  of  miiuite  discolored  spots  all  round  the  outer 
margin  of  the  areola,  where  the  pigmentation  is  fainter,  and  which  are 
generally  described  as  resembling  spots  from  which  the  color  has  been 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  lol 

discharged  by  a  shower  of  water-drops.  Tin's  cliaiioc,  like  the  dai-k- 
eniiig  of  the  primary  areola,  is  more  marked  in  brunettes.  At  this 
period,  especially  in  women  whose  skin  is  of  fine  texture,  whitish  sil- 
very streaks  are  often  seen  on  the  breasts.  They  are  produced  by  the 
stretching  of  the  cutis  vera,  and  are  permanent. 

By  pressure  on  the  l)reasts  a  small  dro])  of  serous-looking  fluid  can 
very  generally  be  forced  out  from  the  nipple,  often  as  early  as  the  third 

Fig.  80. 


// 


\ 


Appearance  of  the  Areola  in  Pregnancy. 

month,  and  on  microscopic  examination  milk-  and  colostrum-globules 
can  be  seen  in  it. 

The  diagnostic  value  of  these  mammary  changes  has  been  variously 
estimated.  When  well  marked  they  are  considered  by  Montgomery  to 
be  certain  signs  of  pregnancy.  To  this  statement,  however,  some 
important  limitations  must  be  made.  In  women  who  have  never  borne 
children  they  no  doubt  are  so  ;  for,  although  various  uterine  and  ova- 
rian disea.ses  produce  some  darkening  of  the  areola,  they  certainly  never 
produce  the  well-marked  changes  above  described.  In  mnltiparte, 
however,  the  areolse  remain  permanently  darkened,  and  in  them  these 
signs  are  much  less  reliable.  /In  first  pre^^nancies  the  presence  of  milk 
in  the  breasts  may  be  considered  an  ahiiost  certain  sign,  and  it  is  one 
which  I  have  rarely  failed  to  detect  even  from  a  comparatively  early 
period.  \  It  is  true  that  there  are  authenticated  instances  of  non-pregnant 
Avomen Slaving  an  abundant  secretion  of  milk,  established  from  mam- 
mary irritation.  Thus,  Baudelocque  presented  to  the  Academv  of 
Surgery  of  Paris  a  young  girl,  eight  years  of  age,  who  had  nursed  her 
little  brother  for  more  than  a  month.  Dr.  Tanner  states — I  do  not 
know  on  what  authority — that  "  it  is  not  uncommon  in  Western  Africa 
for  young  girls  who  have  never  been  pregnant  to  regularlv  employ 


7 


152  pnEayAycY. 

tlicmsclvos  ill  inirsiii<2;  llic  cliiMrcii  of  (ttlicis,  the  iii;iiiiiiiii'  hcinj;  excited 
to  aetion  bv  the  application  of  the  juice  of  one  of  the  Kuphoihiaceaj." 
Lacteal  secretion  Jias  even  been  noticed  in  the  male  hreitst.  lint  these 
exce})tions  to  the  oem-ral  rule  are  so  uncommon  as  merely  to  deserve 
mention  as  curiosities  ;  and  I  have  hardly  ever  been  deceived  in  diair- 
nosing  a  first  jjregnancy  I'rom  the  })resencc  of  even  the  minutest  (juantitv 
of  lacteal  secretion  in  the  breasts,  althoujih  even  then  «»ther  ccjrrobo- 
rative  signs  should  always  be  sought  for.  f  Jn  nmltiparie  the  presence 
ot"  milk  is  by  no  means  so  valuable,  for  it  is  commoli  for  milk  to  remain 
in  the  mamma^  long  after  the  cessation  of  lactation,  even  for  several 
years.)  Tyler  Smith  correctly  says  that  "  suj>j)ression  of  the  milk  in 
persons  who  are  nursing  and  liable  to  impregnation  is  a  more  valuable 
sign  of  pregnancy  than  tlie  converse  condition."  This  is  an  observation 
I  have  frequently  corroborated. 

As  a  diagnostic  sign,  therefore,  the  mammary  appearances  are  of  great 
importance  in  primipane,  and  when  well  marked  they  are  seldom 
likely  to  deceive.  They  are  specially  important  when  we  suspect  i)reg- 
uancy  in  the  immarried,  as  we  can  easily  make  an  excuse  to  look  at  the 
breast  without  ex])laining  to  the  })aticnt  the  reason  ;  and  a  single  glance, 
especially  if  the  patient  be  dark-complexioned,  may  so  far  strengthen 
our  suspicion  as  to  justify  a  more  thorough  examination.  In  married 
multiparoe  they  are  less  to  be  depended  upon. 

/In  connection  Avith  this  subject  may  be  mentioned  various  irregular 
deposits  of  pigment  which  are  frequently  observed.  The  most  connnon 
is  a  clark'^mx)Avnjsl.i  or  yijlLawish.  Im£.  atai'ting  from  the  pubfs  and  imi- 
Diug  up  to  the  ceiltrc  of  tlie  abdomfiU-^sometimes  as  far  as  the  umbilicus 
only,  at  others  forming  an  irregular  ring  round  the  umbilicus  and  reach- 
ing to  the  epigastrium.  It  is,  however,  of  very  uncertain  occurrence, 
being  well  marked  in  some  women,  wiiilc  in  others  it  is  entirely  absent. 
Patches  of  darkened  skin  are  often  observed  about  the  face,  chiefly  on 
the  forehead,  and  this  bronzing  sometimes  gives  a  very  peculiar  a])p.car- 
ance.  Joulin  states  that  it  only  occurs  on  parts  of  the  face  exjioscd  to 
the  sun,  and  that  it  is  therefore  most  frequently  observed  in  women  of 
the  lower  orders  who  are  freely  ex])oscd  to  atmospheric  influences. 
These  pigmentary  changes  are  of  small  diagnostic  value,  and  may  con- 
tinue for  a  considerable  time  after  delivery.  [A  contusion  of  the  cheek 
in  a  pregnant  woman  will  sometimes  be  followed  by  a  dark-brown  spot 
or  liver-mark  that  may  remain  several  months  or  less,  according  to  the 
stage  of  gestation.  We  once  saw  a  well-marked  instance  of  this  in  a  lady 
of  Philadel])hia,  a  young  multi])ara. — Ed.] 

Foetal  Movements. — The  progressive  enlargement  of  the  abdomen; 
and  the  size  of  the  gravid  uterus  at  various  ]K'rio(ls  of  ])regnaii(y,  as  welh 
as  the  method  of  examination  by  means  of  abdominal  paljiation,  have* 
already  been  described  (j)j).  127  and  137).  ' 

We  will  now  consider  the  well-known  phenomena  ])roduced  by  the 
movements  of  the  foetus  \n  virn,  which  arc  m.  fhniilinr  to  all  pregnant 
women.  These,  no  doubt,  take  \\\\\vv  iVoni  ilic  (arlii^i  pci'ind  of  fa'taL 
lije  at  which  the  muscular  ti.>^sue  of  the  fetus  is  suilicicnlly  developed  to 
admit  of  contraction,  but  they  are  not  felt  l)y  the  mother  until  some- 
where about  the  sixteenth  week  of  utcro-ge.station,  the  jirecise  period  at 


iiiayS  Ai\l)  SYML'TOMS  OF  PREGNANCY.  153 

which  they  arc  perceived  varyinti:  considerably  in  difFerent  cases.  The  vF. 
error  of"  the  law  on  this  subject  which  siip})oses  the  child  not  to  be  alive,  ♦  \^ 
or  "  quick,"  until  the  mother  ieels  its  movements,  is  well  known,  and  />^ 
has  fVe(juently  been  ])r()tcsted  against  by  the  medical  ])r(^fession.  The^T 
so-called  nu'ickcniiKi — which  certainly  is  felt  very  suddenly  by  some  w 
women — is  believed  to  depend  on  the  rising  of  tlie  uterine  tumor  suf- 
ficiently high  to  perniit  of  the  impulse  of  the  foetus  being  transmitted  to 
the  abdominal  walls  of  the  mother,  through  the  sensory  nerves  of  which 
its  movements  become  appreciable.  (The  sensation  is  generally  described 
as  being  a  feeble,  fluttering,  which  M'hcn  first  felt  not  unfrccjuently  causes 
unpleasant  nervous  sensations."^  As  the  uterus  enlarges  the  movements 
become  more  and  more  distinct,  and  generally  consist  of  a  series  of 
sharp  blows  or  kicks,  sometimes  quite  appreciable  to  the  naked  eye  and 
causing  distinct  projections  of  the  abdominal  walls.  Their  force  and 
frequency  will  also  vary  during  pregnancy  according  to  circumstances. 
At  times  they  are  very  frequent  and  distressing ;  at  others  the  foetus 
seems  to  be  comparatively  quiet,  and  they  may  even  not  be  felt  for 
several  days  in  succession,  and  thus  unnecessary  fears  as  to  death  of  the 
foetus  often  arise.  The  state  of  the  mother's  health  has  an  undoubted 
influence  upon  them.  They  are  said  to  increase  in  force  after  a  pro- 
longed abstinence  from  food  or  in  certain  positions  of  the  body.  It  is 
certain  that  causes  interfering  with  the  vitality  of  the  foetus  often  pro- 
duce very  irregular  and  tumultuous  movements.  They  can  be  very 
readily  felt  by  the  accoucheur  on  palpating  the  abdomen,  and  sometimes, 
in  the  latter  months,  so  distinctly  as  to  leave  no  doubt  as  to  the  exist- 
ence of  pregnancy.  They  can  also  generally  be  induced  by  placing  one 
hand  on  each  side  of  tlie  abdomen  and  applying  gentle  pressure,  which 
will  induce  foetal  motion  that  can  be  easily  appreciated. 
(As  a  diagnostic  sign  the  existence  of  foetal  movements  has  always 
held  a  high  place,  but  care  should  be  taken  in  relying  on  it.^  It  is  cer- 
tain that  women  are  themselves  very  often  in  error,  and  fancy  they  feel 
the  movements  of  a  foetus  when  none  exists,  being  probably  deceived  by 
irregular  contractions  of  the  abdominal  muscles  or  flatus  within  the 
bowels.  They  may  even  involuntarily  produce  such  intra-abdominal 
movements  as  may  readily  deceive  the  practitioner.  Of  course,  in 
advanced  pregnancy,  when  the  foetal  movements  are  so  marked  as  to  be 
seen  as  well  as  felt,  a  mistake  is  hardly  possible,  and  they  then  con- 
stitute a  certain  sign.  But  in  such  cases  there  is  an  abundance  of  other 
indications  and  little  room  for  doubt.  In  questionable  cases  and  at  an 
early  period  of  pregnancy  the  fact  that  movements  are  not  felt  must  not 
be  taken  as  a  proof  of  the  non-existence  of  pregnancy,  for  they  may  be 
so  feeble  as  not  to  be  perceptible,  or  they  may  be  absent  for  a  consider- 
able period. 

Braxton  Hicks  ^  has  directed  attention  to  the  value,  from  a  diagnostic 
point  of  view,  of  ijitcrmittent  contractions  ot'  tlic  utci-ns  during  prej;- 
nancy.  After  the  uterus  is  snlficicMitly  large  to  be  felt  by  palpation,  if 
the  hand  be  placed  over  it  and  it  be  grasped  for  a  time  M'ithout  using 
any  friction  or  pressure,  it  will  be  observed  to  distinctly  harden  in  a 
manner  that  is  quite  characteristic.     This  intermittent  contraction  occurs 

1  Obst.  Trans.,  1872,  vol.  xiii.  p.  216. 


154  iTjyiyAycy. 

evfiT  five  or  ten  luimitts,  soiiU'tiiiK'.s  <»ftc'iier,  rarely  at  loiij^^er  iiittrvals. 
The  I'aet  that  the  uterus  did  eoutract  \n  this  way  had  beeu  previously 
described,  uiore  especially  by  Tyler  Smith,  mIio  ascribed  it  to  jx-ristaltie 
action.  Jiut  it  is  certain  that  no  one  before  Dr.  Hicks  had  pointed  out 
the  I'act  that  such  contractictns  are  constant  and  normal  concomitants  ot" 
j)rej;nancy,  continuing  during  the  whole  period  ot"  utero-gestation,  and 
forming  a  ready  and  reliable  means  ot"  distinguishing  the  uterine  tumor 
from  other  abdominal  enlargements.  Since  reading  Dr.  Hicks'  paper 
I  have  paid  considerable  attention  to  this  sigu,  which  I  have  never 
i'ailcd  to  detect,  even  in  the  retroverted  gi'avid  uterus  contained  entirely 
in  the  pelvic  cavity,  and  I  am  disposed  entirely  to  agree  Avith  him  as  to 
its  great  value  in  diagnosis.  If  the  hand  be  ke})t  steadily  on  the  uterus, 
its  alternate  hardening  and  relaxation  can  be  appreciated  with  the 
greatest  ease.  The  advantages  which  tliis  sign  has  over  the  foetal  move- 
ments are  that  it  is  constant,  that  it  is  not  liable  to  be  simulated  by 
anythin<>-  else,  and  that  it  is  independent  of  the  life  of  the  child,  being 
equally  appreciable  when  the  uterus  contains  a  degenerated  ovum  or 
dead  fa?tus.  The  only  condition  likely  to  give  rise  to  error  is  an 
enlargement  of  the  uterus  in  consequence  of  contents  other  than  the 
results  of  conception,  such  as  retained  menses  or  a  polypus.  The  histoiy 
of  such  cases — wliich  are,  moreover,  of  extreme  rarity — would  easily 
prevent  any  mistake.  As  a  corroborative  sign  of  pregnancy,  therel'ore, 
I  should  give  these  intermittent  contractions  a  higli  i)lace. 

[In  rare  instances  these  intermittent  contractions  are  accomj)anied  by 
a  sensation  of  pain,  such  as  to  alarm  the  patient  and  give  rise  to  feai-s 
of  a  miscarriage  ;  but  it  will  be  found  that  the  uterus  gives  no  evidence 
of  a  design  to  exjiel  its  contents.  In  one  case  attended  by  the  writer 
the  pains  lasted  three  weeks,  and  finally  ceased  under  an  opiate  treat- 
ment, the  contractions  continuing,  but  without  sensation  :  the  foetus  wiis 
born  at  maturity. — Ed.] 

The  vaginal  signs  of  pregnancy  are  of  considerable  importance 
in  diagnosis.  They  are  chiefly  the  changes  which  may  be  detected  in 
the  cervix,  and  the  so-called  huUoUement,  which  depends  on  the  mobility 
of  the  fretus  in  the  licpior  amnii. 

Softening  of  the  Cervix. — The  alterations  in  the  density  and  appa- 
rent length  of  the  cervix  have  been  already  described  (p.  138),  A\'hen 
pregnancy  has  advanced  l)eyon(l  the  fifth  month  the  peculiar  velvety 
soitness  oT  ilic  <(rvix  i-  \  (  i  y  (  haincteristic,  and  aflbrds  a  strong  corrol> 
orative  sign,  but  one  which  it  would  be  unsafe  to  rely  on  by  itself, 
inasmuch  as  very  similar  alterations  may  be  produced  by  various 
causes.  AVhcn,  however,  in  a  supposed  case  of  jiregnancy  advanced 
beyond  the  period  indicated  the  cervix  is  found  to  l)e  elongated,  dense, 
and  projecting  into  the  vaginal  canal,  the  non-existence  of  pregnancy 
may  be  safely  inferred.  (Therefore  the  negative  value  of  this  sign  is 
of  more  importance  than  the  positive.)  In  connection  with  this  maybe 
mentioned  a  sign  of  pregnancy  to  wliich  attention  has  recently  been 
drawn  by  Hegar.'  It  consists  in  a  peculiar  elasticity  of  the  lower  seg- 
ments of  the  uterus,  made  out  by  vaginal  or  rectal  examination.  It 
may  serve  to  differentiate  the  pregnant  uterus  from  certain   uterine 

»  CenlralbhU  fiir  Gyndk.,  1886,  Bd.  xi.  p.  805. 


STG2fS  AND  SYMPTCMS  OF  PREGNANCY.  15o 

enlartiXMuents  due  to  tiiinors  in  those  cases  in  wliicli  the  diagnosis  is 
donhtl'id. 

Ballottement,  when  distinctly  made  out,  is  a  very  valuahle  indica- 
tion of  ])rc!j:nancy.  It  consists  in  the  disphicenient,  by  the  exaniinint^ 
finoer,  of  the  fetus,  which  floats  up  in  the  liquor  anuiii,  and  falls  back 
ao;ain  on  the  tip  of  the  finger  with  a  slight  tap  M'hich  is  exceedingly 
characteristic. 

In  order  to  practise  it  most  easily  the  patient  is  placed  on  a  couch  or 
bed  in  a  position  midway  between  sitting  and  lying,  by  which  the  ver- 
tical diameter  of  the  uterine  cavity  is  brought  into  correspondence  with 
that  of  the  pelvis.  Two  fingers  of  the  right  hand  are  then  passed  high 
up  into  the  vagina  in  front  of  the  cervix.  The  uterus  being  now 
steadied  from  without  by  the  left  hand,  the  intravaginal  fiugers  press 
the  uterine  wall  suddenly  upward,  when,  if  pregnancy  exist,  the  foetus 
is  displaced,  and  in  a  moment  falls  back  again,  imparting  a  distinct 
impulse  to  the  fingers.  When  easily  appreciable  it  may  be  considered 
as  a  certain  sign,  for  although  an  auteflexed  fundus  or  a  calculus  in  the 
bladder  may  give  rise  to  somewhat  similar  sensations,  the  absence  of 
other  indications  of  pregnancy  would  readily  prevent  error.  Ballotte- 
ment is  practised  between  the  fourth  and  seventh  months.  Before  the 
former  time  the  fcetus  is  too  small,  M'hile  at  a  later  period  it  is  relatively 
too  large  and  can  no  longer  be  easily  made  to  rise  upward  in  the  sur- 
rounding liquor  amnii.  The  absence  of  ballottement  must  not  be  taken 
as  proving  the  non-existence  of  pregnancy,  for  it  may  be  inappreciable 
from  a  variety  of  causes,  such  as  abnormal  presentations  or  the  implan- 
tation of  the  placenta  upon  the  cervix  uteri. 

Vaginal  Pulsation. — There  are  also  some  other  vaginal  signs  of 
pregnancy  of  secondary  consequence.  Amongst  these  is  the  vagiual 
pulsation,  pointed  out  by  Osiander,  resulting  from  the  enlargement  of 
the  vaginal  arteries,  which  may  sometimes  be  felt  beating  at  an  early 
period.  Often  this  pulsation  is  very  distinct,  and  at  other  times  it  can- 
not be  felt  at  all,  and  it  is  altogether  unreliable,  as  a  similar  pulsation 
may  be  felt  in  various  uterine  diseases. 

Uterine  Fluctuation. — Dr.  Rasch  has  drawn  atteutiou  to  a  pre- 
viously undescribed  sign  which  he  believes  to  be  of  importance  in  the 
diagnosis  of  early  i)regnancy.^  It  consists  in  the  detectiou  of  fluctua- 
tion through  the  anterior  uterine  wall,  depending  on  the  presence  of 
the  liquor  amnii.  In  order  to  make  this  out,  two  fingers  of  the  right 
hand  must  be  used,  as  in  ballottement,  while  the  uterus  is  steadied 
through  the  abdomen.  Dr.  Rasch  states  that  by  this  means  the 
enlarged  uterus  in  pregnancy  can  easily  be  distinguished  from  the 
enlargement  depending  on  other  causes,  and  that  fluctuation  can  always 
be  felt  as  early  as  the  second  month.  If  it  is  associated  with  suppressed 
menstruation  and  darkened  areola?,  he  considers  it  a  certain  sign.  In 
order  to  detect  it,  however,  considerable  experience  in  making  vaginal 
examinations  is  essential,  and  it  can  hardly  be  dejiended  on  for  general  use. 

A  peculiar  deep  violet  hue  of  the  vaginal  nuicous  meml)rane  was 
relied  on  by  Jacquemin-  and  Kliige  as  affording  a  readily-observed 

1  Brit.  Med.  Jonrn.,  1873,  vol.  ii.  p.  '2(il. 

"■  The  credit  of  first  drawing  attention  to  this  sign  of  pregnancy  is  generally  given 


156  rREG  NANCY. 

iiulii-atiuii  ul'  j)iv<;naiu'y.  In  most  cases  it  is  well  marked  ;  sometimes, 
indeetl,  the  c'luin«i;e  of  color  is  very  intense,  and  it  evidently  dej)ends  on 
the  eoii<>estion  ])r()dueed  by  ])ressure  of  the  enlarjicd  uterus.  Chad- 
uick  has  recently  rein  vest  ijiated  this  si}:;n,  and  altrihutcs  to  it  a  hi^h 
diaiiiidstic  valiu'.'  It  has  been  generally  stated  U)  be  unreliable,  as 
a  similar  discoloration  is  said  to  be  jiroduced  by  the  ])ressnre  of 
larne  uterine  libroids.  This,  however,  Chadwick  declares  is  not  the 
case. 

Auscultatory  Signs  of  Pregnancy. — By  far  the  most  important 

si<ins  are  those  which  can  be  detected   by  abdominal  auscultation,  and 

one  of  these — the  hearioi;  of  the  fa'tal  lieart-s()unds — forms  the  only 

jsign  Mliich,y>r/-  -sc  and  in  the  absence  of  all  others,  is  })erfcctly  reliable. 

The  fact  that  the  sounds  of  the  fwtal  heart  are  audilile  during 
advanced  pregnancy  was  first  pointed  out  by  Mayor  of  (Geneva  in 
1.S18,  and  the  main  facts  in  connection  with  foetal  auscultation  were 
subsequently  worked  out  by  Kei'garadec,  Nacgele,  Evory  Kennedy, 
and  other  observers.  The  pulsations  first  become  audible,  as  a  I'ule, 
in  the  course  of  the  fifth  month  or  about  the  middle  of  the  fourth 
month.  In  exceptional  circumstances  and  by  practised  observers  they 
have  been  heard  earlier.  Depaul  believes  that  he  detected  them  as 
early  as  the  eleventh  week,  and  Routh  has  also  detected  theni  at  an 
earlier  period  by  vaginal  stethoscopy,  which,  however,  for  obvious 
reasons,  cannot  be  ordinarily  employed.  Naegele  never  heard  them 
before  the  eighteenth  week,  more  generally  at  the  end  of  the  twen- 
tieth, and  for  practical  purposes  the  pregnancy  must  be  advanced  to 
the  fifth  month  before  we  can  reasonably  expect  to  detect  them.  From 
this  period  up  to  term  they  can  almost  always  be  heard,  if  not  at 
the  first  ■attemj)t,  at  least  afterward  to  a  certainty,  if  Ave  have  the 
opportunity  of  making  repeated  examinations.  Accidental  circum- 
stances, such  as  the  presence  of  an  unusual  amount  of  fiatus  in  the 
intestines,  may  deaden  the  sounds  for  a  time,  but  not    ]iermanently. 

Dejxiul  only  failed  to  hear  them  in  8  cases  out  of  0()6  examined 
during  the  last  three  months  of  pregnancy;  and  out  of  180  cases 
Avhich  Dr.  Anderson  of  Glasgow  carefully  examined,  he  oidy  iailcd 
in  12,  and  in  each  of  these  the  child  was  stillborn.  They  therefore 
form  not  only  a  most  certain  indication  of  pregnancy,  but  of  the  life 
of  the  ftetus  also. 

The  sound  has  always  been  likened  to  the  double  tic-tac  (»f  a 
watch  heard  through  a  pillow,  which  it  closely  resembles.  It  consists 
of  two  beats,  se])aratcd  by  a  short  interval,  the  first  being  the  loudest 
and  most  distinct,  the  second  being  sometimes  inaudible.  The  ra- 
pidity of  the  fo'tal  ])ulsations  forms  an  imjiortant  jueans  of  distin- 
guishing them  from  transmitted  maternal  ])ulsations,  with  which  they 
might  be  confounded.  Their  average  number  is  stated  by  Slater, 
who  made  numerous  observations  on  this  point,  to  be  lo2,  but  some- 

to  .Tacqiieniier,  a  distinmiishod  I'^rendi  ()l)stetriciaii,  wlio  wrote  a  work  im  mi<lwiferv. 
It  is  due,  liowever,  to  .Jao(|ueinin,  iiiedecin  en  elief  de  la  prison  de  Mazas,  and  is,  in 
fact,  attril)Uted  to  liini  in  .Jacqueniier's  work  {Mdiincl  des  AccouchcmoilK  par  J.  Jacque- 
mier,  Paris,  184G,  vol.  i.  p.  215). 

*  Transactions  of  (he  Aiiierican  GyncEcological  Society,  1886,  vol.  ii.  ji.  309. 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  157 

times  thoy  ix'aeli  as  high  as  140,  and  sometiines  as  low  as  120.  It 
will  thus  be  seen  that  the  pulsations  are  always  much  more  rapid 
than  those  of  the  mother's  heart,  unless,  indeed,  the  latter  be  unduly 
accelerated  by  transient  luental  emotion  or  disease.  To  avoid  mis- 
takes, whenever  the  f(etal  heart  is  heard  its  rate  of  pulsation  should 
be  carefully  counted  and  compared  with  that  of  the  mother's  pulse ; 
if  the  rates  ditler,  we  may  be  sure  that  no  error  has  been  made.  The 
ra][)idity  of  the  foetal  pulsations  remains,  as  a  rule,  the  same  during 
the  whole  period  of  pregnancy,  while  their  intensity  gradually  increases. 
They  may,  however,  be  temporajrily  increased  or  diminished  in  frequency 
by  disturbing  causes,  such  as  the  pressure  of  the  stethoscope,  which, 
exciting  tumultuous  movements  of  the  foetus,  may  induce  greatly 
increased  frequency  of  its  heart-beats.  So  also  during  labor,  after  the 
escape  of  the  liquor  amnii,  when  the  contractions  of  the  uterus  have  a 
very  distinct  influence  on  the  foetus,  they  may  be  greatly  modified.  An 
acceleration  or  irregularity  of  the  pulsations  made  out  in  the  course  of 
a  prolonged  labor  may  thus  be  of  great  practical  importance,  by  indi- 
cating the  necessity  for  prompt  interference.  Similar  alterations,  asso- 
ciated with  tumultuous  and  unusual  foetal  movements  felt  by  the  mother 
toward  the  end  of  pregnancy,  may  point  to  danger  to  the  life  of  the 
foetus  during  the  latter  months,  and  may  even  justify  the  induction  of 
premature  labor.  This  is  especially  the  case  in  women  who  have  pre- 
viously given  birth  to  a  succession  of  dead  children  owing  to  disease  of 
the  placenta,  and  in  them  careful  and  frequently  repeated  auscultations 
may  warn  us  of  the  impending  danger. 

The  rapidity  of  the  foetal  heart  has  been  supposed  by  some  to  aiford 
a  means  of  determining  the  sex  of  the  child  before  birth.  [  Franken- 
hauser,  who  first  directed  attention  to  this  point,  is  of  opinion  that  the 
average  rate  of  puj^ations  of  the  heart  is  considerably  less  in  male  than 
in  female  children,  averag-ing  124_,in  the  minute  in  the  former,  as 
against  144  in  the  latter,  j  Steinbach  makes  the  difference  somewhat 
less — viz.  l31  for  males  a/id  138  for  females.  He  predicted  the  sex 
correctly  by  this  means  in  45  out  of  57  cases,  while  Frankenhauser  was 
correct  in  the  whole  50  cases  which  he  specially  examined  with  reference 
to  the  point.  Dr.  Hutton  of  New  York^  was  also  correct  in  7  cases  he 
fixed  on  for  trial.  Devilliers  found  the  difference  in  the  sexes  to  be  the 
same  as  Steinbach :  he  attributes  it,  however,  to  the  size  and  weight 
rather  than  to  the  sex  of  the  child,  and  believes  the  pulsations  to  be 
least  numerous  in  large  and  well-developed  children.  As  male  children 
are  usually  larger  than  female,  he  thus  explains  the  relatively  less  fre- 
quent pulsations  of  their  hearts.  Dr.  Gumming  of  Edinburgh  also 
believes  that  the  weight  of  the  child  has  considerable  influence  on 
the  frequency  of  its  cardiac  pulsations,  so  that  a  largo  female  child 
may  have  a  slower  pulse  than  a  small  male.^  The  point,  however,  is 
more  curious  than  practical,  and  the  rapidity  of  the  pulsations  certainly 
would  not  justify  any  positive  prediction  on  the  subject.  Circumstances 
influencing  the  maternal  circulation  seem  to  have  no  influence  on  that 
of  the  foetus. 

1  New  York  Med.  Journ.,  1 872,  vol.  xvi.  p.  68. 

'^  Edin.  Med.  Journ.,  vol.  1875-76,  pp.  230,  317,  418. 


158  PBEGyA.\C'Y. 

Tlu'  lalal  iK'art-souiuls  arc  ii,t'nc'rally  })roj)a<:;atet]  best  by  the  back  of 
the  eliikl,  aiul  arc  tlierefbre  incst  easily  au(lible  when  this  is  iii  C(»iitaet 
uith  the  anterior  wall  of  the  uterus,  as  is  the  ease  in  the  larjre  ninjority 
of  j)rci;naneics.  \\'hen  the  child  is  placed  in  the  dorso-posterior  posi- 
tion the  sounds  have  to  traverse  a  lari^er  amount  of  the  li(|U<jr  anniii,  and 
are  further  nioditied  In'  the  interposition  of  the  lo-tal  limbs.  They  :u"e, 
therefore,  less  easily  heard  in  such  eases,  but  even  in  them  they  can 
almost  always  be  made  out.  f  As  the  foetus  most  i'requently  lies  with  the 
oecij)ut  over  the  brim  of  th^i)elvis,  and  the  back  of  the  child  toward 
the  left  side  of  the  mother,  the  heart-sounds  are  usually  most  distinctly 
audible  at  a  point  midway  between  the  umbilicus  and  the  left  anteriur 
superior  -piiu  <if  the  iliiun.\J  In  the  next  most  common  ])osition,  iu 
mIhcIi  the  Inuk  of  the  chiki  lies  to  the  right  lumbar  region  of  the 
mother,  they  are  generally  heard  at  a  corresponding  point  at  the  right 
side,  but  in  this  case  they  are  frequently  more  readily  made  out  in  the 
right  flank,  being  then  transmitted  through  the  thorax  of  the  child, 
Avhich  is  in  contact  with  the  side  of  the  uterus.  In  breech  cases,  on  the 
other  hand,  the  heart-sounds  are  generally  heard  most  distinctly  ahove 
the  umbilicus,  and  either  to  the  right  or  left  according  to  the  side 
toward  M'hich  the  back  of  the  child  is  placed.  It  will  thus  ha  seen 
that  the  place  at  which  the  foetal  heart-sounds  are  heard  varies  with  the 
position  of  the  fcetus;  and  this,  when  combined  with  the  information 
derived  from  ])alpation,  affords  a  ready  means  of  ascertaining  the  })res- 
entation  of  the  child  before  labor.  The  sounds  are  only  audible  over 
a  limited  space,  about  two  or  three  inches  in  diameter ;  therefore,  if  we 
fail  to  detect  them  in  one  place,  a  careful  exploration  of  the  whole 
uterine  tumor  is  necessary  before  we  are  satisfied  that  they  cannot  be 
heard. 

The  only  mistake  that  is  likely  to  be  made  is  taking  the  maternal 
pulsations,  transmitted  through  the  uterine  tumor,  for  those  of  the  fretal 
heart.  A  little  care  will  easily  prevent  this  error,  and  the  frecpiency  of 
the  mother's  ]:>ulse  should  always  be  ascertained  before  counting  the  suj)- 
posed  foetal  pulsations.  If  these  are  found  to  be  120  or  more,  while  the 
mother's  pulse  is  only  70  or  80,  no  mistake  is  ])0ssible.  If  the  latter  is 
abnormally  quickened,  greater  care  may  be  necessary,  but  even  then  the 
rate  of  pulsation  of  each  Avill  be  dissimilar.  Braxton  Hicks'  has 
pointed  out  that  in  tedious  labor,  when  the  nuiscular  j)owcrs  of  the 
mother  are  exhausted,  the  muscular  subsurrus  may  produce  a  sound 
closely  resembling  the  fretal  pulsation  ;  but  error  from  this  source  is 
obviously  very  imjn-obable. 

In  listening  for  the  fVctal  heart-sound  the  jvatient  should  be  ]ilaced  on 
her  back,  with  the  shoulders  elevated  and  the  knees  flexed.  The  sur- 
face of  the  abdomen  should  be  uncovered,  and  an  oi'dinary  stcthoscoj)e 
em])loycd,  the  end  of  which  must  be  pressed  firndy  on  the  tumor,  so  as 
to  depress  the  abdominal  walls.  The  most  absolute  stillness  is  neces- 
sary, as  it  is  often  far  from  easy  to  hear  the  sounds.  Sometimes,  after 
failing  with  the  ordinary  stethoscope,  I  have  succeeded  with  the  bin- 
aural, which  remarkably  intensifies  them.  When  once  heard  they  are 
most  easily  counted  during  a  space  of  five  seconds,  as  on  account  of 
»  Obsl.  Trans.,  1874,  vol.  xv.  p.  187. 


SlOyS  AND  SYMPTOMS  OF  PBEGNANCY.  159 

their    frequency    it    is    not   always    possible    to    follow    them    over   a 
longer  period. 

ANHien  the  f(otal  heart-sounds  are  heard  distinctly,  pregnancy  may  be 
absolutely  and  certainly  diagnosed.  Tiie  fact  that  we  do  not  hear  them 
does  not,"  however,  preclude  tlie  ])0ssibility  of  gestation,  for  the  frx'tus 
mav  be  dead  or  the  sounds  temporarily  inaudible. 

Other  Sounds  heard  in  Pregnancy. — There  are  some  other  sounds 
heard  in  auscultation  wiiic-h  are  of  very  secondary  diagnostic  value.  One 
of  these  is  the  so-called  umbUAmlyv  J\ndc  souffle,  which  was  first  pointed 
out  by  Evory  Kennedy.  It  consists  oif  a  single  blowing  murnuu-  syn- 
chronous with  the  fetal  heart-sounds,  and  most  distinctly  heard  in  the 
immediate  vicinity  of  the  point  where  these  are  most  audible.  INIost 
authors  believe  it  to  be  produced  by  pressure  on  the  cord,  either  when 
it  is  placed  between  a  hard  part  of  the  foetus  and  ihe'ut'erine  walls  or  is 
twisted  round  the  child's  ueck.  Schroeder  and  Hecker  detected  it  in  14 
or  15  per  cent,  of  all  cases,  and  the  latter  believed  it  to  be  caused  by 
flexure  of  the  first  portion  of  the  cord  near  the  umbilicus.  For 
practical  purposes  it  is  quite  valueless,  and  need  only  be  mentioned 
as  a  phenomenon  which  an  experienced  auscultator  may  occasionally 
detect. 

The  Viterme  souffle  is  a  peculiar  single  whizzing  murmur  which  is 
almost  always  audible  ou  auscultation.  It  varies  very  remarkably  in 
character  and  position.  Sometimes  it  is  a  gentle  blowing  or  even 
musical  murmur ;  at  others  it  is  loud,  harsh,  and  scraping ;  sometimes 
continuous,  sometimes  intermittent.  It  may  also  be  heard  at  any  point 
of  the 'uterus,  but  most  frequently  low  down  and  to  one  or  other  side, 
more  rarely  above  the  umbilicus  or  toward  the  fundus ;  and  it  often 
changes  its  position  so  as  to  be  heard  at  a  subsequent  auscultation  at  a 
point  where  it  was  previously  inaudible.  {It  may  be  heard  over  a  space 
of  an  inch  or  two  only,  gr  in  some  cases  over  the  whole  uterine  tumor;' 
or,  again,  it  may  sometimes  be  detected  simultaneously  over  two  entirely 
distinct  portions  of  the  uterus.  (  It  is  generally  to  be  heard  earlier  than 
the  foetal  heart-sounds,  often  as^soon  as  the  uterus  rises  above  the  brim 
of  the  pelvis,  and  it  can  almost  always  be  detected  after  the  commence- 
ment of  the  fourth  month. \  The  sound  becomes  curiously  modified  by 
the  uterine  contractions  during  labor,  becoming  louder  and  more  intense 
before  the  pain  comes  ou,  disappearing  during  its  acme,  and  again  being 
heard  as  it  goes  off.  Hicks  attributes  to  a  similar  cause — viz.  the  uterine 
contractions  duringjpreguancy — the  frequent  variations  in  the  souuti 
which  are  characteristic"  of  it.^  The  uterine  souffle  is  also  audible  after 
the  death  of  the  foetus,  and  it  is  believed  by  some  to  be  modified  and  to 
become  more  continuously  harsh  when  that  event  has  taken  place. 

A^ery  various  explanations  have  been  given  of  the  causes  of  this  sound. 
For  long  it  was  supposed  to  be  formed  in  the  vessels  of  the  placenta,  and 
hence  the  name  " placental  souffle"  by  which  it  is  often  talked  of,  or,  if 
not  in  the  placenta,  inthe  uterine  vessels  in  its  immediate  neigliborhood. 
The  non-placental  origin  of  the  sound  is  sufficiently  demonstrated  by  the 
fact  that  it  may  be  heard  for  a  considerable  time  after  the  expulsion  of 
the  placenta.     Some  have  supposed  that  it  is  not  formed  in  the  uterus  at 

'  Op.  0(7.,  p.  223. 


\ 


1()0  PREGNANCY. 

all,  Imt  ill  llic  inatcnial  vessels,  t'sjx'cially  tlic  aorta  and  llie  iliac  art t-rics, 
<nvin<2:  to  the  pressure  to  wliieli  they  are  siihjeeted  by  the  j^ravid  uterus. 
Tl»e  extreme  irregularity  ol'  the  sound,  its  occiisional  disappearance,  and 
its  variable  site  seem  to  be  conclusive  against  this  view,  (riie  theory 
which  refers  the  snund  to  the  uferiiie  vcshds  is  that  which  has  received 
most  adliereiii.-,  and  wliicli  hot  iiiccis  the  facts  of  the  case;  but  it  is  l)y 
no  means  easy,  or  even  possible,  to  account  for  the  exact  mode  of  its  pro- 
duction in  them.j  Kach  of  the  explanations  which  have  been  given  is 
open  to  some  objection.  It  is  far  from  unliUely  that  the  intermittent 
contractions  of  the  uterine  fibres,  which  are  known  to  occur  during  the 
whole  course  of  pregnancy,  may  have  much  to  do  with  it,  by  modifying 
at  intervals  the  rapidity  of  the  circulation  in  the  vessels.  Its  produc- 
tion in  this  manner  may  also  be  favored  by  the  chlorotic  state  of  the 
blood,  to  which  Cazeaux  and  Scanzoni  are  inclined  to  attribute  an  im- 
portant influence,  likening  it  to  the  auffimic  murmur  so  frequently  heard 
in  the  vessels  in  weakly  women. 

From  a  diagnostic  point  of  view  the  uterine  souffle  is  of  very  second- 
ary importance,  because  a  similar  sound  is  very  generally  a,udible  iii 
large  fibi-oid  tumors  of  the  uterus,  and  even  in  some  few  ovarian  tumors  ; 
it  is,  therefore,  of  little  or  no  value  in  assisting  us  to  decide  the  charac- 
ter of  the  abdominal  enlargement.  The  supposed  dependence  of  the 
sound  on  the  placental  circulation  has  caused  its  site  to  be  often  identi- 
fied with  that  of  the  placenta.  It  is,  however,  most  frequently  heard  at 
the  lower  part  of  the  uterus,  while  the  j)lacenta  is  generally  attached 
near  the  fundus,  so  that  its  position  cannot  be  taken  as  any  safe  guide 
in  determining  the  situation  of  that  organ. 

Occasionally,  in  practising  auscultation  irregular  sounds  of  brief  dura- 
tion may  be  heard  which  are  not  susceptible  of  accurate  description,  and 
which  doubtless  depend  on  the  sudden  movement  of  the  foetus  in  the 
liquor  amnii  or  on  the  im])act  of  its  lindjs  on  the  uterine  walls.  When 
heard  distinctly  they  are  characteristic  of  ])regnancy,  and  they  may  be 
sometimes  heard  when  the  other  sounds  cannot  be  detected.  They  are, 
however,  so  irregular  and  so  often  entirely  absent  that  they  can  hardly 
be  looked  upon  in  any  other  light  than  as  occasional  phenomena. 

Two  other  sounds  have  been  described  as  being  sometimes  audible, 
which  may  be  mentioned  as  matters  of  interest,  but  Avhich  are  of  no 
diagnostic  value.  One  is  a  rustling  sound,  said  by  Stoltz  to  be  audible 
in  cases  in  which  the  fU'tus  is  dead,  and  which  he  refers  to  gaseous 
decomposition  of  the  liquor  amnii ;  its  existence  is,  however,  extremely 
problematical.  The  other  is  a  sound  heard  after  the  birth  of  the  child, 
and  referred  by  Caillant  to  the  separation  of  the  placental  adhesions. 
He  describes  it  as  a  series  of  ra})id,  short  scratching  sounds,  similar  to 
those  produced  l)y  drawing  the  nails  across  the  seat  of  a  horsehair  sofa. 
Simj)S()n  '  admitted  the  existence  of  the  sound,  but  believed  that  it  is 
produced  by  the  mere  physical  crushing  of  the  placenta,  and  artificially 
imitated  it  out  of  the  body  by  forcing  the  placenta  through  an  a{)erture 
the  size  of  the  os  uteri. 

It  will  be  seen,  then,  that  although  tliere  are  numerous  signs  and 
symptoms  accomi)anying  pregnancy,  many  of  them  are  unreliable  by 

1  Selected  Obstet.  Worh,  p.  151. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  IGl 

tlicmsclvcs,  and  apt  to  mislead.  Those  which  may  he  confi(h'ntly 
depended  ou  are  tiie  [)iilsati<)iis  of  the  IVjctal  lieart,  which,  however, 
fail  us  in  cases  of  dead  children  ;  the  fcetal  movements,  when  distinctly 
made  out ;  hallotteiiient ;  the  intermittent  contractions  of  the  uterus  ;  and 
to  these  we  may  safely  add  the  presence  <jf  milk  in  the  breasts,  provided 
we  have  to  do  with  a  tirst  pregnancy. 

The  remainder  are  of  importance  in  leading  us  to  suspect  pregnancy 
and  in  corroborating  and  strengthening  other  symptoms,  but  they  do 
not,  of  themselves,  justify  a  positive  diagnosis. 


CHAPTER  V. 

THE  DIFFERENTIAL  DIAGNOSIS  OF  PEEGNANCY.— SPURIOUS  PREG- 
NANCY.—THE  DURATION  OF  PREGNANCY.— SIGNS  OF  RECENT 
PREGNANCY. 

The  differential  diagnosis  of  pregnancy  has  of  late  years  assumed 
much  importance  on  account  of  the  advance  of  abdominal  surgery. 
The  cases  are  so  numerous  in  which  even  the  most  experienced  prac- 
titioners have  fallen  into  error,  and  in  which  the  abdomen  has  been  laid 
open  in  ignorance  of  the  fact  that  pregnancy  existed,  that  the  subject 
becomes  one  of  the  greatest  consequence.  Fortunately,  it  is  less  so  from 
an  obstetrical  than  from  a  gynecological  point  of  view,  inasmuch  as  the 
converse  error,  of  mistaking  some  other  condition  for  pregnancy,  is  of 
far  less  consequence,  as  it  is  one  which  time  will  always  rectify.  But 
even  in  this  way  carelessness  may  lead  to  very  serious  injury  to  the 
character,  if  not  to  the  health,  of  the  patient ;  and  it  will  be  well  to  refer 
briefly  to  some  of  the  conditions  most  liable  to  be  mistaken  for  preg- 
nancy, and  to  the  mode  of  distinguishing  them. 

Adr|x)se  enlargement  of  the  abdomen  may  obscure  the  diagnosis  bv 
preventmg  the  detection  of  the  uterus  ;  and  if,  as  is  not  uncommon  wMtli 
women  of  great  obesity,  it  is  associated  with  irregular  menstruation,  the 
increased  size  of  the  abdomen  might  be  supposed  to  depend  on  preg- 
nancy. The  absence  of  corroborative  signs,  such  as  auscultatory  phe- 
nomena, mammary  changes,  and  the  hardness  of  the  cervix  as  felt  j^er 
vaginam,  make  it  easy  to  avoid  this  error. 

Distension  of  the  uterus  bv  rctaiiK'd  menstrual  fluid  or  watery  secre- 
tions is  an  occurrence  TjFTaritv  that  could  seldom  give  rise  to  error. 
Still,  it  occasionally  happens  that  the  uterus  becomes  enlarged  in  this 
way,  sometimes  reaching  even  to  the  level  of  the  umbilicus,  and  that  the 
physical  character  of  the  tumor  is  not  unlike  that  of  the  gravid  uterus. 
The  best  safeguard  against  mistakes  will  be  the  previous  history  of  the 
case,  which  will  always  be  different  from  that  of  ordinary  pregnancy. 
Retention  of  the  menses  almost  always  occurs  from  some  physical  obstruc- 
tion to  the  exit  of  the  fluid,  such  as  imperforate  hymen ;  or  if  it  occur 
in  women  who  have  already  menstruated,  we  may  usually  trace  a  his- 
11 


1G2  PREGNANCY. 

torv  of  some  cnuso,  siicli  as  iiiHaniniation  following  an  aiitoccck'nt  labor, 
M'liu'li  has  prodiu'id  occlusion  of  some  part  ol"  the  genital  tract.  The 
existence  of  a  ])elvic  tinnor  in  a  girl  who  has  never  menstruated  \\\\\  of 
itself  give  rise  to  suspicion,  as  pi-egnancv  under  such  circumstances  is  of 
extreme  rarity.  It  will  also  be  found  that  general  symptoujs  iiave 
existed  for  a  period  of  time  considerably  longer  than  the  suj)j)osed  dura- 
tion of  ])regnaney,  as  judged  of  by  the  size  of  the  tumor.  Tlje  most 
characteristic  of  them  are  ])eriodic  attacks  of  pain  due  to  the  addition, 
at  each  monthly  period,  to  the  (juantity  of  retained  meiisti'ual  Huid. 
Whenever,  from  any  of  these  reasons,  suspicion  of  the  true  character  of 
the  case  has  arisen,  a  careful  vaginal  examination  will  generally  clear  it 
up.  In  most  cases  the  obstruction  will  be  in  the  vagina,  and  is  at  once 
detected,  the  vaginal  canal  above  it,  as  felt  per  rectum,  being  greatly  dis- 
tended by  fluid  ;  and  we  may  also  find  the  bulging  and  imperforate 
liymen  protruding  through  the  vulva.  The  al)>enee  of  mammary 
changes  and  of  ballottement  will  materially  aid  us  in  forming  a 
diagnosis. 

The  engorged  and  enlarged  uterus  fre(|uentlv  met  with  in  woivien  suf- 
fering from  uterine  disease  might  readily  be  taken  for  an  early  i>reg- 
nancy  if  it  happened  to  be  associated  with  amenorrhoea.  A  little  time 
would,  of  course,  soon  clear  up  the  point  l)v  shoMing  that  j)rogressive 
increase  in  size,  as  in  pregnancy,  does  not  take  place.  This  mistake 
could  only  be  made  at  an  early  stage  of  pregnancy,  when  a  positive 
diagnosis  is  never  possible.  The  accompanying  symjitoms — pain, 
inability  to  walk,  and  tenderness  of  the  uterus  on  j)ressure — would 
prevent  such  an  error. 

Ascites.  ;/f/:  se,  could  hardly  be  mistaken  for  pregnancy,  for  the  uni- 
fornTTTisteiision  and  evident  fluctuation,  the  absence  of  any  definite 
tumor,  the  site  of  resonance  on  percussion  changing  in  accordance  with 
alteration  of  the  position  of  the  woman,  and  the  unchanged  cervix  and 
uterus,  should  be  sufficient  to  clear  up  any  doubt.  Pregnancy  may, 
however,  exist  with  ascites,  and  this  combination  may  be  difficult  to 
detect,  and  might  readily  i)e  mistaken  for  ovarian  disease  associated  with 
ascites.  The  existence  of  mammary  changes,  the  ])resence  of  the  soft- 
ened cervix,  ballottement,  and  auscultation — provided  the  sounds  were 
not  masked  by  the  surrounding  fluid — would  afford  the  best  means  of 
diagnosing  such  a  case. 

One  of  the  most  frequent  sources  of  difficulty  is  the  differential  diag- 
nosis of  large  abdominal  tumors,  either  fibroid  or  ovarian,  or  of  some 
enlargements  due  to  malignant  disease  of  the  i)eritoneum  or  ai)dominal 
viscera.  The  most  experienced  have  been  occasionally  deceived  under 
such  circumstances.  As  a  rule,  the  presence  of  menstruation  will  pre- 
vent error,  as  this  generally  continues  in  ovarian  disease,  while  in 
fibroids  it  is  often  exce&sive.  The  character  of  the  tumor — the  fluc- 
tuation in  ovarian  disease,  the  hard  nodidar  masses  in  fibroid — and  the 
histon'  of  the  case,  especially  the  length  of  time  the  tumor  has  existed, 
■will  aid  in  diagnosis,  wliile  the  al)sence  of  cervical  softening  (vide  p.  141) 
and  of  auscultatory  phenomena  will  fiui:her  be  of  material  value  in 
forming  a  conclusion.  Some  of  the  most  difficult  cases  to  diagnose 
are  those  in  which  pregnancy  complicates  ovarian  or  fibroid  disease. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  163 

Then  tlie  tiinior  iiiuy  more  or  less  completely  obscure  tlic  ])liysical  signs 
of  pregnancy.  The  usual  shape  of"  the  abdomen  will  generally  be 
altered  considerably,  and  we  may  be  able  to  distinguish  the  gravid 
uterus,  separated  from  the  ovarian  tumor  by  a  distinct  sulcus  or  with 
the  fibroid  masses  cropping  out  from  its  surface.  Our  chief  reliance 
must  then  be  ])laced  in  the  alteration  of  the  cervix  and  in  the  auscul- 
tatory signs  of  pregnancy. 

Spurious  Pregnancy. — The  condition  most  likely  to  give  rise  to 
errors  is  that  very  interesting  and  j)eculiar  state  known  as  xynrious 
pix^nanci/.  In  this  most  of  the  usual  phenomena  of  })regnaney  are 
so  strangely  simulated  that  accurate  diagnosis  is  often  far  from  easy. 
There  are  hardly  any  of  the  more  apparent  symptoms  of  pregnancy 
which  may  not  be  present  in  marked  cases  of  this  kind.  The  abdomen 
may  become  prominent,  the  areolae  altered,  menstruation  arrested,  and 
aj)parent  foetal  motions  felt,  and,  unless  suspicion  is  aroused  and  a  care- 
ful physical  examination  made,  both  the  patient  and  the  practitioner  may 
easily  be  deceived. 

There  is  no  period  of  the  childbearing  life  in  which  spurious  preg- 
nancy may  not  be  met  with ;  but  it  is  most  likely  to  occur  in  elderly 
women  about  the  climacteric  period,  when  it  is  generally  associated  with 
ovarian  irritation  connected  with  the  change  of  life ;  or  in  younger 
women  who  are  either  very  desirous  of  finding  themselves  pregnant, 
or  who,  being  unmarried,  have  subjected  themselves  to  the  chance  of 
being  so.  fin.  all  cases  the  mental  faculties  have  nnich  to  do  with  its 
production,  and  there  is  generany°eitlier  very  marked  hysteria  or  even 
a  condition  closely  allied  to  insanity.  /  Spurious  i)regnancy  is  by  no 
means  confined  to  the  human  race.  It  is  well  known  to  occur  in  many 
of  the  lower  animals.  Harvey  related  instances  in  bitches,  either  after 
unsuccessful  intercourse  or  in  connection  with  their  being  in  heat,  even 
when  no  intercourse  had  occurred.  In  such  cases  the  abdomen  swelled 
and  i3lilk_.a|5i5eared  in  the  mammse.  Similar  phenomena  are  also 
occasionally  met  with  in  the  cow.  In  these  instances,  as  in  the 
human  female,  there  is  probably  some  morbid  irritation  of  the 
ovarian  system. 

The  ])hysical  phenomena  are  often  very  well  marked.  The  ap])ar- 
ent  enlargement  is  sometimes  very  great,  and  it  seems  to  be  produced  by 
a  projection  forward  of  the  abdominal  contents,  due  to  dei)ression  of  the 
diaphragm,  together  with  rigidity  of  the  abdominal  muscles,  and  may 
even  closely  simulate  the  uterine  tumor  on  palpation.  After  the  climac- 
teric it  is  frequently  associated,  as  Gooch  pointed  out,  with  an  undue 
deposit  of  fat  in  the  abdominal  walls  and  omentum,  so  that  there  may 
be  even  some  dulness  on  percussion  instead  of  resonance  of  the  intestines. 
The  foetal  movements  are  curiously  and  exactly  sinndated,  either  bv  in- 
voluntary contractions  of  the  abdominal  walls  or  by  the  movement  of 
flatus  in  the  intestines.  The  patient  also  generally  fancies  that  she  suf- 
fers from  the  usual  sympathetic  disorders  of  ]>reonancy,  and  thus  her 
account  of  her  symptoms  will  still  further  tend  to  mislead. 

Not  only  may  the  supposed  pregnancy  continue,  but  at  Avhat  would 
be  the  natural  term  of  deli  very  all  the  ])henomena  of  labor  may  super- 
vene.    Many  authentic  cases  are  on  record  in  which  regular  pains  came 


1G4  PREGNANCY. 

on,  and  oontinncd  to  increase  in  force  and  Imnuncy  until  the  actual  con- 
dition was  (lia;^n;()S((l.  Such  nn'stakcs,  however,  arc  only  likclv  to  ha)i|)cn 
M'licn  the  >tatcincnts  ol"  the  patient  have  luen  received  without  further 
inquirv.  ^\  hen  once  an  accurate  examination  lia.s  heen  luade  err(»r  is  no 
longer  possible. 

We  shall  trenerally  find  that  some  of  the  phenomena  ol"  prcfrnanev  are 
absent.  Possibly,  menstruation,  more  or  less  irregular,  may  have  con- 
tinued, f  Kxaminalion  jtcr  vayinum  will  at  once  clear  up  the  case  by 
showing  that  the  uterus  is  not  enlarged  and  that  the  cervix  is  inialtcred.N 
It  n)ay  then  be  very  difficult  to  convince  the  ])atient  or  her  friends  that 
her  symptoms  have  misled  her,  and  for  this  purpose  the  inhalation  of 
chloroform  is  of  great  value.  As  consciousness  is  abolished  the  semi- 
voluntary  projection  of  the  abdominal  muscles  is  prevented,  the  large 
apparent  tumor  vanishes,  and  the  l)ystanders  can  be  readily  con- 
vinced that  none  exists.  As  the  patient  recovers  the  tumor  again 
ap])ears. 

Duration  of  Pregnancy. — The  duration  of  pregnauc-y  in  the  human 
female  has  always  formed  a  fruitful  theme  for  discussion  amongst  oi)ste- 
trieians.  The  reasons  uhich  render  the  point  difficult  of  decision  are 
obvious.  As  the  large  majority  of  cases  occur  in  married  women,  in 
whom  intercourse  occurs  frequently,  there  is  no  means  of  knowing  the 
precise  period  at  which  conception  took  place.  The  only  datum  which 
exists  for  the  calculation  of  the  probable  date  of  delivery  is  the  cessation 
of  menstruation,  (it  is  quite  possible,  however,  and  indeed  })robable, 
that  conception  occurred  in  a  considerable  nundjer  of  instances  not  im- 
mediately after  the  last  perirxL  Imt  immediately  before  the  proj)er  epoch 
for  the  occurrence  of  the  next.)  Hence,  as  the  interval  Ijctweeu  the  end 
of  one  menstruation  and  the  commencement  of  the  next  avei'ages  twenty- 
five  days,  an  error  to  that  extent  is  always  possible.  Another  source  of 
fallacy  is  the  fact,  which  has  generally  been  overlooked,  that  even  a  sin- 
gle coitus  does  not  fix  the  date  of  conception,  but  only  that  of  insemi- 
nation. It  is  Mell  known  that  in  many  of  the  lower  animals  the 
fertilization  of  the  ovule  does  not  take  j)lace  until  several  days  after 
copulation,  the  spermatozoa  remaining  in  the  interval  in  a  state  of  active 
vitality  within  the  genital  tract.  It  has  been  shown  by  Marion  Sims 
that  living  spermatozoa  exist  in  the  cervical  canal  in  the  human  female 
some  days  after  intercourse.  It  is  very  probable,  therefore,  that  in  the 
human  female,  as  in  the  lower  animals,  a  c<tnsideral)lc  but  uid<nown  in- 
terval occurs  lietween  insemination  and  actual  imi)regnation,  which  may 
render  calculations  as  to  the  precise  duiation  of  pregnancy  altogether 
unreliable. 

A  large  mass  of  statistical  observations  exist  respecting  the  average 
duration  of  gestation  Avhich  have  been  drawn  u]>  and  collated  from  « 
numerous  sources.  It  would  serve  no  j^ractical  purpose  to  re]>i'int  the 
volunn'nous  tables  on  this  subject  that  are  contained  in  obstetrical  woiks. 
They  are  based  on  tw  o  princi])al  methods  of  calculation  :  Fii'st,  wc  have 
the  length  of  time  between  the  cessation  of  menstruation  and  delivery. 
This  is  found  to  vary  very  considerably,  but  the  largest  ])ercentage  of  de- 
liveries occurs  between  the  ■274th  and  2S0th  day  after  the  cessation  of  men- 
struation, the  averaL^e  dav  beinu  the  278tli  ;  but  in  indiviilual  instances 


DIFFKRENTIAL   DIAdNOSIS   OF  PREGNANCY.  IGo 

ven'  considerable  variations  botli  above  and  below  these  limits  arc  found 
to  exist.  Next,  we  have  a  series  of  cases,  from  various  sources,  in  which 
only  one  coitus  Mas  believed  to  have  taken  place.  Those  are  naturally 
open  to  some  doubt,  but,  on  the  wliole,  they  may  be  taken  as  affording 
tolerably  fair  grounds  for  cahndation.  Here,  as  in  the  other  mode  of 
calculation,  there  are  marked  variations,  the  average  length  of  time, 
as  estimated  from  a  considerable  collection  of  cases,  being  275  days 
after  the  single  intercourse.  It  may  therefore  be  taken  as  certain  that 
there  is  no  definite  time  which  we  can  calculate  on  as  being  the 
pro])er  duration  of  ])regiian('y,  and  consequently  no  method  of  esti- 
mating the  probable  date  of  delivery  on  which  we  can  absolutely 
rely. 

Methods  of  Predicting  the  Probable  Date  of  Delivery. — The 
jirediction  of  the  time  at  which  the  confinement  may  be  expected  is, 
however,  a  point  of  considerable  practical  importance,  and  one  on  which 
the  medical  attendant  is  always  consulted.  Various  methods  of  making 
the  calculation  have  been  recommended.  It  has  been  customary  in  this 
country,  according  to  the  recommendation  of  Montgomery,  to  fix  upon 
ten  lunar  months,  or  280  days,  as  the  probable  period  of  gestation,  and, 
as  conception  is  supposed  to  occur  shortly  after  the  cessation  of  menstru- 
ation, to  add  this  number  of  days  to  any  day  within  the  first  week  after 
the  last  menstrual  period  as  the  most  probable  period  of  delivery.  As, 
however,  278  days  is  found  to  be  the  average  duration  of  gestation  after 
the  cessation  of  menstruation,  and  as  the  method  makes  the  calculation 
vary  from  281  to  287  days,  it  is  evidently  liable  to  fix  too  late  a  date. 
Naegele's  method  was  to  count  seven  days  from  the  first  appearance  of 
the  last  menstrual  period,  and  then  reckon  backward  three  months  as  the 
probable  date.  Thus,  if  a  patient  last  commenced  to  menstruate  on 
August  10,  counting  in  this  way  from  August  17  would  give  May  17 
as  the  probable  date  of  the  delivery. 

Matthews  Duncan  has  ])aid  more  attention  than  any  one  else  to  the 
prediction  of  the  date  of  delivery.     His  method  of  calculating  is  based 
on  the  fact  of  278  days  being  the  average  time  between  the  cessation  of 
menstruation    and  parturition  ;  and  he  claims  to  have  had  a   greater 
average  of  success  in  his  predictions  than  on  any  other  plan.     His  rule 
is  as  follows  (  ^'  Find  the  day  on  which  the  female  ceased  to  menstruate,  / 
or  the  first  day  of  being  what  she  calls  '  well.'  Take  that  day  nine  months  \ 
forward  as  275 — unless  February  is  included,  in  which  case  it  is  taken  ' 
as  273 — days.     To  this  add  tbrge  days  in  the  former  case,  or  five  if  , 
February  is  in  the  count,  to  make  up  the  278.     This  278th  day  should 
then  be  fixed  on  as  the  middle  of  the  week,  or,  to  make  the  prediction  i 
the  more  accurate,  of  the  fortnight,  in  which  the  confinement  is  likely  \ 
to  occur,  by  which  means  allowance  is  made  for  the  average  variation 
of  either  excess  or  deficiency."/ 

Various  periodoscopes  and  titoles  for  fiicilitating  the  calculation  have 
been  made.  The  periodoscope  of  Dr.  Tyler  Smith  is  very  useful  for 
reference  in  the  consulting-room,  giving  at  a  glance  a  variety  of  infor- 
mation, such  as  the  probable  period  of  quickening,  the  dates  for  the 
induction  of  premature  labor,  etc.  The  following  table,  prepared  by 
Dr.  Protheroe  Smith,  is  also  easily  read  and  is  very  serviceable  : 


166  rREG  NANCY. 

Table  for  Calculating  tiik  I'euiod  of  Utero-Gestation.' 


Nine 

Calendar  Months. 

Ten  Lunar  Months. 

From 

To 

Days. 

To 

Days. 

Jamiarv 

J 

September 

30 

273 

October 

7 

280 

Kebniarv 

October 

31 

273 

Novembei 

1 

280 

Mairli 

November 

30 

275 

December 

5 

280 

April 

i 

December 

31 

275 

January 

o 

280 

Mav 

January 

31 

276 

February 

4 

280 

June 

February 

28 

273 

March 

7 

280 

July 

.Alarc'li 

31 

274 

April 

« 

280 

August 

April 

30 

273 

Mav 

7 

280 

September 

Mav 

31 

273 

June 

7 

280 

Oc-tolier 

June 

30 

273 

July 

7 

280 

November 

July 

31 

273 

August 

7 

280 

December 

August 

31 

274 

i     September 

I 

G 

280 

The  (late  at  which  the  cjuickcniug  has  been  perceived  is  relied  on  by 
many  practitioners,  and  still  more  by  patients,  in  calculating  tlie  ])roba- 
ble  date  of  delivery,  as  it  is  generally  sii])poscd  to  occur  at  the  middle 
of  pregnancy.  The  great  variations,  however,  (if  the  time  at  Avhich 
this  phenomcDon  is  first  perceived,  and  the  difficulty  uhich  is  .'^o  often 
experienced  of  a.scerlaining  its  presence  with  any  certainty,  render  it  a 
very  fallacious  guide.  The  only  times  at  which  the  perception  of 
quickening  is  likely  to  prove  of  any  real  value  are  Avhen  impregnation 
has  occurred  during  lactation  (when  men.'^truation  is  normally  absent), 
or  when  menstruation  is  so  uncertain  and  irregular  that  the  date  of  its 
last  appearance  cannot  be  ascertained.  As  quickening  is  mo.-^t  com- 
moidy  felt  during  the  fourth  month — more  frequently  in  its  first  than 
in  its  last  fortnight — it  may  thus  afford  the  only  guide  we  can  obtain, 
and  that  an  uncertain  one,  for  predicting  the  date  of  delivery. 

Is  Protraction  of  Gestation  Possible  ? — From  a  medico-legal 
point  of  view  the  question  of  the  jiossilile  ])rolracti()n  oi"  pregnaiuy 
beyond  the  average  time,  and  of  the  limits  within  which  such  pr(»trac- 
tion  can  be  admitted,  is  of  very  great  iui})ortance.  The  law  <in  this 
point  varies  considerably  in  different  countries.  Thus  in  France  it 
is  laid  down  that  legitimacy  cannot  be  contested  until  '500  days  have 
elai>sed  from  the  death  of  the  husband  or  the  latent  po.^sible  opportu- 
nitv  for  sexual  intereoiu'se.  This  limit  is  also  adopted  by  Austria, 
while  in  Prussia  it  is  fixed  at  .')()2  days.  In  Fngland  and  America  no 
fixed  date  is  admitted,  but  while  280  days  is  admitted  as  the  "  legiti- 
mum  tempus  pariendi,"  each  case  in  which  legitimacy  is  questioned  is  to 
be  decided  on  its  own  merits.  At  the  early  ])art  of  the  century  the 
question  was  much  discus.sed  by  the  leading  ol)stetricians  in  eoimcction 

'  The  above  ol)stetric  "  Ready  Reckoner"  consists  of  two  columns,  one  of  calenibir,  the 
other  of  lunar  months,  and  maybe  read  as  follows:  A  patient  has  cea.se(l  to  men- 
struate on  July  1  :  her  confinement  may  be  expected  at  soonest  about  March  31  (the 
end  of  nine  calcmhtr  months),  or  at  latest  on  April  li  {the  end  of  ten  lunar  nionlli><). 
Another  has  ceased  to  menstruate  on  January  20  ;  her  confinement  maybe  expected 
on  September  .'W,  plus  20  days  {Ike  end  of  nine  calendar  nionlk'<),  at  soonest,  or  on  October 
7,  plus  20  days  {the  end  of  ten  lunar  monlhs),  at  latest. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  167 

with  the  celebrated  (jiarchier  peerage  case,  and  u  eonsideruhlc  dillcrence 
of  opinion  existed  among  them.  Since  that  time  many  ai)parently  per- 
fectly reliable  cases  have  been  recorded  in  which  tlie  dnration  of  gesta- 
tion was  obvionsly  nuich  beyond  the  average,  and  in  which  all  sources 
of  fallacy  were  carefully  excluded. 

Not  to  burden  these  pages  with  a  number  of  cases,  it  may  suffice  to 
refer,  as  examples  of  protraction,  to  four  well-known  instances  recorded 
by  Simpson,^  in  which  the  pregnancy  extended  respectively  to  336,  332, 
319,  and  324  days  after  the  cessation  of  the  last  menstrual  })eriod.  In 
these,  as  in  all  cases  of  protracted  gestation,  there  is  the  possible  source 
of  error  that  impregnation  may  have  occurred  just  before  the  expected 
advent  of  the  next  period.  Making  an  allowance  of  23  days  in  each 
instance  for  this,  we  even  then  have  a  number  of  days  nuich  above  the 
average — viz.  313,  309,  296,  and  301.  Numerous  instances  as  curious 
may  be  found  scattered  through  obstetric  literature.  Indeed,  the  expe- 
rience of  most  accoucheurs  will  parallel  such  cases,  which  may  be  more 
common  than  is  generally  supposed,  inasmuch  as  they  are  only  likely  to 
attract  attention  when  the  husband  has  been  separated  from  the  wife 
beyond  the  average  and  expected  duration  of  the  pregnancy. 

The  evidence  in  favor  of  the  possible  prolongation  of  gestation  is 
greatly  strengthened  by  what  is  known  to  occur  in  the  lower  animals. 
In  some  of  these,  as  in  the  cow  and  the  mare,  the  precise  period  of 
insemination  is  known  to  a  certainty,  as  only  a  single  coitus  is  permit- 
ted. Many  tables  of  this  kind  have  been  constructed,  and  it  has  been 
shown  that  there  is  in  them  a  very  considerable  variation.  In  some 
cases  in  the  cow  it  has  been  found  that  delivery  took  place  45  days,  and 
in  the  mare  43  days,  after  the  calculated  date.  Analogy  would  go 
strongly  to  show  that  what  is  known  to  a  certainty  to  occur  in  the  lower 
animals  may  also  take  place  in  the  human  female.  The  fact,  indeed,  is 
now  very  generally  admitted  ;  but  we  are  still  unable  to  fix  with  any 
degree  of  precision  on  the  extreme  limit  to  which  protraction  is  pos- 
sible. Some  practitioners  have  given  cases  in  which,  on  data  which  they 
believe  to  be  satisfactory,  pregnancy  has  been  extremely  protracted  ; 
thus,  Meigs  and  Adler  record  instances  which  they  believed  to  have 
been  prolonged  to  over  a  year  in  one  case  and  over  fourteen  months 
in  the  other.  These  are,  however,  so  problematical  that  little  weight 
can  be  attached  to  them.  On  the  wdiole,  it  would  hardly  be  safe  to 
conclude  that  pregnancy  can  go  more  than  three  or  four  weeks  beyond 
the  average  time.  This  conclusion  is  justified  by  the  cases  we  possess 
in  which  pregnancy  followed  a  single  coitus,  the  longest  of  which  Avas 
295  days. 

Dr.  Duncan  ^  is  inclined  to  refuse  credence  to  every  case  of  supposed 
protraction  unless  the  size  and  weight  of  the  child  are  above  the  aver- 
age, believing  that  lengthened  gestation  must  of  necessity  cause  increased 
growth  of  the  child.  This  point  requires  further  investigation,  and  it 
cannot  be  taken  as  proved  that  the  foetus  necessarily  nuist  be  large 
because  it  has  been  retained  longer  than  usual  in  utero  ;  or,  even  if  this 
be  admitted,  it  may  have  been  originally  small,  and  so  at  the  end  of 
the  protracted  gestation  be  little  above  the  average  weight.     There  are, 

^  Obstet.  Memoirs,  p.  84.  *  Fecundity  and  Fertility,  p.  348. 


KJS  PR  I'JG  NANCY. 

however,  many  eases  whieli  eertaiiily  j)iuve  that  a  prolonged  prej^naiiey 
is  at  least  often  associated  witii  an  unusually  (leveloj)ed  tJjetus.  J)r. 
Dnnean  himself  eites  several,  and  a  very  interestin<i:  one  is  mentioned 
by  Leishman,  in  Mhicli  delivery  took  ])laee  295  days  ai"ter  a  sin<rle 
coitus,  the  child  weij^hing  12   pounds  .'i  ounces. 

It  seems  possible  that  in  some  cases  of  j»rotracted  pregnancy  labor 
actually  came  on  at  the  average  time,  but  on  account  of  faulty  posi- 
tions of  the  uterus  or  other  obstructing  cause  the  pains  were  inef- 
fective and  ultimately  died  away,  not  recurring  for  a  consideiable 
time.  Joulin  relates  some  instances  of  this  kind.  In  one  of  them 
the  labor  was  expected  from  the  20th  to  the  25th  of  October.  He 
was  sumiuoned  on  the  2.3(1,  and  found  the  })ains  regular  and  active, 
but  ineffective;  after  lasting  the  Avliole  of  the  24th  and  25th  they 
died  away,  and  delivery  did  not  take  ])lacc  until  November  25th,  after 
the  lapse  of  a  month.  In  this  instance  the  apparent  cause  of  diffi- 
culty was  extreme  anterior  obliquity  of  the  uterus.  A  j)recisely  sim- 
ilar case  came  under  my  own  observation.  The  lady  ceased  to  men- 
struate on  March  16,  1870.  On  December  12 — that  is,  on  the  273d 
day — strong  labor-pains  came  on,  the  os  dilated  to  the  size  of  a 
florin,  and  the  membranes  became  tense  and  prominent  with  each 
pain.  After  lasting  all  night  they  gradually  died  away,  and  did  not 
recur  until  January  12,  304  days  from  the  cessation  of  the  last  jK-riod. 
Here  there  was  no  assignal)le  cause  of  obstruction,  and  the  laboi-,  when 
it  did  come  on,  was  natural  and  easy. 

The  curious  fact  tliat  in  both  these  cases,  as  in  others  of  the  same 
kind  that  are  recorded,  labor  came  on  exactly  a  month  after  the  previous 
ineffectual  attempt  at  its  establishment,  affords,  so  far  as  it  goes,  an  argu- 
ment in  favor  of  the  view  maintained  by  many  that  labor  is  apt  to  come 
on  at  what  would  have  been  a  menstrual  period. 

Signs  of  Recent  Delivery. — From  a  forensic  point  of  view  it  often 
l)ecomes  of  imj^ortance  to  be  able  to  give  a  reliable  opinion  as  to  the  fact 
of  delivery  having  occurred,  and  a  few  Mords  may  be  here  said  as  to  the 
signs  of  recent  delivery.  Our  opinion  is  only  likely  to  be  sought  in  cases 
in  which  the  fact  of  delivery  is  denied,  and  in  which  we  must,  therefore, 
entirely  rely  on  the  results  of  a  physical  examination.  If  this  be  under- 
taken within  the  first  foi-tniuht  after  ]al)(ir.  a  ])i)sitive  ciniclusi'in  cnn  FTe 
readily  arrived  at. 

At  this  time  the  abdniuiiia]  walls  will  still  be  found  loose  and  flaccid, 
and  bearing  very  evident  marks  of  extreme  distension  in  the  cracks Tnd 
fissures  of  the  cutis  vera.  These  remain  permanent  for  the  rest  of  the 
])atient's  life,  and  may  be  safely  assumed  to  be  signs  of  an  antecedent 
jireguancy,  ])rovided  we  can  be  certain  tiiat  no  other  cause  of  extreme 
abdominal  distension  has  existed,  such  as  ascites  or  ovarian  tumor. 

Within  the  first  few  days  after  delivery  the  hard  round  ball  fi)rmed 
by  the  contracted  and  empty  uterus  can  easily  be  felt  l)y  abdominal  pal- 
pation, and  more  certainly  by  combined  external  and  internal  examina- 
tion. The  process  of  involution,  however,  by  which  the  uterus  is 
reduced  to  its  normal  size,  is  so  rapid  that  after  the  Hrst  week  it  can  no 
longer  be  made  out  above  the  l)rim  of  the  pelvis,  (in  cases  in  which  an 
accurate  diagnosis  is  of  importance  the  increased  length  of  the  uterus  can 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  169 

be  uscertaiued  by  the  uterine  .sound,  and  its  eavity  will  measure  more 
than  the  normal  2^-  inches  for  at  least  a  month  after  delivery^  It 
should  not  be  forgotten  that  the  uterine  parietes  an;  now  underu^oing 
fatty  degeneration,  and  tliat  they  are  more  tliau  usually  soft  and  friable, 
so  tiiat  the  sound  should  be  used  with  great  eaution  and  only  when  a 
positive  ojiiniou  is  essential.  Tiie  state  of  the  cervix  and  of  tlie  vagina 
may  afford  useful  information.  Immediately  after  delivery  the  cervix 
hangs  loose  and  patulous  in  the  vagina,  but  it  rapidly  contracts,  and  tlie 
internal  os  is  generally  entirely  closed  after  the  eighth  or  tenth  day. 
The  remainder  of  the  cervix  is  longer  in  returning  to  its  normal  shape 
and  consistency.  It  is  generally  permanently  altered  after  delivery,  the 
external  os  remaining  fissured  and  transverse,  instead  of  circular  with 
smooth  margins  as  in  virgins.  The  vagina  is  at  first  lax,  swollen,  and 
dilated,  but  these  signs  rapidly  disappear,  and  cannot  be  satisfactorily 
made  out  after  the  first  few  days.  The  absence  jof  the^foiirchette  may 
be  recognized,  and  is  a  persistent  sign. 

The  presence  of  thejochia  affords  a  valuable  sign  of  recent  delivery. 
For  the  first  few  days  they  are  sanguineous,  and  contain  numerous 
blood-corpuscles,  epithelial  scales,  and  the  debris  of  the  decidua.  After 
the  fifth  day  they  generally  change  in  color,  and  become  pale  and  green- 
ish, and  from  the  eighth  or  ninth  day  till  about  a  month  after  delivery 
they  have  the  appearance  of  thick  opalescent  mucus.  They  have,  how- 
ever, a  peculiar,  heavy,  sickening  odor,  which  should  prevent  their  being 
mistaken  for  either  menstruation  or  leucorrhceal  discharge. 

The  appeai^ance  of  the  breasts  will  also  aid  the  decision,  for  it  is 
impossible  for  the  patient  to  conceal  the  turgid,  swollen  condition  of 
the  mammae,  with  the  darkened  areola,  and,  al)0ve  all,  the  presence  of 
milk.  (If,  on  microscopic  examination,  the  milk  is  found  to  contain 
colostrum-corpuscles,  the  fact  of  very  recent  delivery  is  certain. )  In 
women  who  do  not  nurse  it  should  be  remembered  that  the  secretion  of 
milk  often  rapidly  disappears,  so  that  its  absence  cannot  be  taken  as  a 
sign  that  delivery  has  not  taken  place.  On  the  whole,  there  should  be 
no  difficulty  in  deciding  that  a  woman  has  been  delivered,  as  some  of 
the  signs  are  persistent  for  the  rest  of  her  life ;  but  it  is  not  so  easy, 
unless  we  see  the  case  within  the  first  eight  or  ten  days,  to  say  how  long 
it  is  since  labor  took  place. 


170 


PREGNANCY. 


(  IIAITKU   VI. 

ABNORMAL  PREGNANCY,  INCLUDING  MULTIPLE  PREGNANCY, 
SUPEKIXETATION,  EXTRA-UTERINE  FCETATION,  AND  MISSED 
LAIiOK. 

I'lii:  nc<'urronce  of"  more  than  one  fretus  in  ntero  is  far  iVdUi  uiic()iii- 
nion,  bnt  there  arc  cirennistances  connected  with  it  which  ju.stity  the 
conchision  that  ])hn"al  births  must  not  be  classified  as  natural  forms  of 
preirnancy.  The  reasons  for  this  statement  have  been  well  collected  by 
Dr.  Arthur  Mitchell/  who  conclusively  slutws  thatfnot  only  is  there  a 
direct  increase  of  risk  both  to  the  mother  and  her  of1s|)ring,  but  that 
I  many  abnormalities,  such  as  idiocy,  imbccilitv,  and  !)odilv  deformitv, 
If  occur  with  much  <:;reater  frequency  in  twins  than  in  single-born  chil- 
dren.^) He  concludes  that  "  the  whole  history  of  twin  births  is  excep- 
tional, indicates  imperfect  development  and  feeble  organization  in  the 
jM'oduct,  and  leads  us  to  regard  twinning  in  the  human  sj)ecies  as  a 
de[)arture  from  the  ]>hysiological  rule,  and  therefore  injurious  to  all 
concerned." 

The  frequency  of  multiple  births  varies  considerably  under  differ- 
ent circumstanccs.^Taking  the  average  of  a  large  number  of  ca.ses  collected 
by  authors  in  various  countries,  we  find  that  (t\vin  pregnancies  occur 
about  once  in  87  labors  ;  triplets,  once  in  7679^  A  certain  number  of 
quadruple  ])regnancies,  and  some  cases  of  early  abortion  in  which  there 
were  five  foetuses,  are  recorded,  so  that  there  can  l)e  no  doubt  of  thejios- 
sibility  of  such  occiuTcnces  ;  but  they  are  so  extremely  uncommon  that 
they  may  be  looked  upon  as  rare  exceptions,  the  relative  frequency  of 
which  can  hardly  be  determined. 

The  frequency  of  nnilti|)le  ]iregnancv  varies  remarkably  in  different 
races  and  countries.     The  following  table"  ^vill  show  this  at  a  glance: 


Relative  Frequency  of  Multiple  Pregnancies  in  Europe. 


Countries. 


England 

Austria 

Grand  Diicliy  of  Baden 

Scotland     .  " 

France    

Ireland 

Mecklenburg-Sclivveiin 

Norway 

Prussia 

Russia 

Saxony  

Switzerland 

Wiirteniberg 


Proportion  of 

Twin  to  Single 

Births. 


1  :  116 


94 
89 
95 
99 
64 
68.9 


1  :    81.62 


89 

50.05 

79 


1  :  102 
1:  862 


Proportion  of 
Iriplets. 


1  :  6720 

1  :  6575 

1  :  8256 
1  :  4995 
1  :  6436 
1  :  5442 
1  :  7820 
1  :  4054 
1  :  1000 

1  :  6464 


Proportion  of 
Ciuadruplcts. 


1  :  2,074.306 
1  :  167,226 
1  :      183.236 

1  :     .394,690 

1  :     400,000 

1  :     110.99L 


'  Med.  Times  and  Gnz.,  Nov.,  1862. 


'  Piiech,  Des  Naissances  multiples. 


ABNORMAL  rUEG NANCY.  171 

It  will  be  seen  that  the  lar<>;est  proportion  of  nuilti[)le  l)irth.s  occurs  in 
Kiissia,  and  that  the  number  of  triple  births  is  "greatest  where  twin 
preoiianc;ies  arc  most  frequent.  Puech  concludes  that  tiie  number  of 
inuhi|)le  pregnancies  is  in  direct  pro[)ortion  to  the  general  fecundity  of 
the  inhabitants. 

Dr.  Duncan  has  deduced  some  interesting  laws  with  regard  to  the 
production  of  twins  from  a  large  number  of  statistical  observa- 
tions;' especially  that  (the  tendency  to  the  production  of  twins  in- 
creases as  the  age  of  the  woman  advances^  and  is  greater  in  eacii 
succeeding  pregnancy,  exception  being  made  'for  the  first  pngiumcy, 
in  which  it  is  greater  than  in  any  other.  Newly-married  women 
appear  more  likely  to  have  twins  the  older  they  are.  There  can  be  no 
doul)t  that  there  is  often  a  strong  hereditary  tendency  in  individual 
families  to  multiple  births.  A  remarkable  instance  of  this  kind  is 
recorded  by  Mr.  Ciu-genven,^  in  which  a  woman  had  four  twin  preg- 
nancies, her  mother  and  aunt  each  one,  and  her  grandmother  two. 
Simpson  mentions  a  case  of  quadruplets,  consisting  of  three  males  and 
one  female,  who  all  survivetl,  the  female  subsequently  giving  birth  to 
triplets,^ 

Sex  of  Children. — In  the  largest  number  of  cases  of  twins  the  chil- 
dren  are  of  opposite  sexes,  next  most  frequently  there  are  two  females, 
and  twin  males  are  the  most  uncommon.  Thus,  out  of  59,178  labors, 
Simpson  calculates  that  twin  male  and  female  occurred  once  in  199 
labors,  twin  females  once  in  226,  and  twin  males  once  in  258.  The 
proportion  of  male  to  female  births  is  also  notably  less  in  twin  than 
in  single  pregnancies. 

Size  of  Foetuses. — Twins,  and  a  fortiori  triplets,  are  almost  alwaysi 
smaller  and  less  perfectly  developed  than  single  children.  Hence  the' 
chances  of  their  survival  are  nuich  less,  and  Clarke  calculates  the 
mortality  amongst  twin  children  as  1  out  of  13.  Of  triplets,  indeed, 
it  is  comparatively  rare  that  all  survive,  while  in  quadruplets  premature 
labor  and  the  death  of  the  foetuses  are  almost  certain.  '  It  is  a  common 
observation  that  twins  are  often  unequally  developed  at  birth.  By  some 
this  diiference  is  attributed  to  one  of  them  beino;  of  a  different  asre  to 
the  other.  (  It  is  probable,  however,  that  in  most  of  these  cases  the  full 
development  of  one  fretus  has  been  interfered  with  by  pressure  of  tlie. 
other.  This  is  far  from  unconamonly  carried  to  the  extent  of  destroy- 
ing one  of  the  twins,  which  is  expelled  at  term  mummified  and 
flattened  between  the  living  child  and  the  uterine  wall.  In  other 
cases,  when  the  foetus  dies  it  may  be  expelled  without  terminating 
the  pregnancy,  the  other  being  retained  in  utero  and  born  at  term  ; 
and  those  who  disbelieve  in  the  possibility  of  superfoetatioii  explain  in 
this  way  the  cases  in  which  it  is  believed  to  have  occurred. 

Multiple  pregnancies  depend  on  various  causes.  (The  most  common  j 
is  probably  the  simultaneous  or  nearly  simultaneous  maturation  and] 
rupture  (»f  two  ( Jraalian  fullicles,  the  ovules  becoming  impregnatiMl  atj 
or  about  the  same  time.  \  it  by  no  means  necessarily  follows,  even  if  < 
more  than  one  follicle  should  rupture  at  once,  that  both  ovules  should 

1  On  Fecundity,  Fertillti/,  (Did  SUrilili/,  p.  99. 

2  Obst.  Trans.',  1870,  vol.  xi.  p.  lUG.'  "  Obst.  Worh,  p.  830. 


172  j'lih'ayAycY. 

hv  iinprojjnatcil.  This  is  provt'd  l>y  tlic  ocfiirronco  of  cases  in  \vlii<li 
there  are  two  eoi-pora  hiti-a  with  (»iily  (Hie  JM'tiis.  There  are  miiii('r<tn> 
facts  to  prove  that  ovules  thi'owii  otV  within  a  short  time  of"  eacli  other 
juay  become  separately  imju'cgnated,  as  in  cases  in  wliich  negro  women 
liave  given  birth  to  twins,  one  of  which  was  pure  negro,  the  other  half- 
caste. 
I  It  may  happen,  however,  that  a  single  Graafian  follicle  contains  more 
than  one  oviileJas  lias  actually  been  observed  before  its  ru])ture;  or,  as 
is  not  uncoinmon  in  the  egg  of  the  iowl,  an  ovule  may  contain  a  double 
germ,  each  of  which  may  give  rise  to  a  scpai'ate  fcetus. 

An'ang-eraent  of  the  Foetal  Membranes  and  Placentae. — The 
various  modes  in  which  twins  may  originate  explain  satisfactorily  the 
variations  which  are  met  with  in  the  arrangement  of  the  fo'tal  mem- 
branes and  in  the  form  aufl  connections  of  the  placentie.  ^n  a  large 
proportion  of  cases  there  nve  two  distinct  bags  oi'  membranes,  the  sep- 
tum betweeu  them  being  composed  of  lour  layers — viz.  the  chorion  and 
amnion  of  each  ovum  J  The  placenta  are  jilsg  entirely  separate.  Here  I 
it  is  obvious  that  each  twin  is  developed  from  a  distinct  ovum,  having! 
its  own  chorion  and  amnion.  On  arriving  in  the  uterus  it  is  prob- 
able that  each  ovum  becomes  fixed  independently  in  the  mucous 
membrane  and  is  surrounded  by  its  own  decidua  reflexa.  As  growth 
advances  the  decidua  reflexa  generally  atroj)hies  from  pressure,  as 
it  is  not  usual  to  find  more  than  four  layers  of  meinln-ane  in  the 
septum  separating  the  ova.  l^In  other  cases  there  is  only  one  diorion, 
within  Avhich  are  two  distinct  amnions,  the  se])tum  tlicn  consisting 
of  two  lavei's  only.A  Then  the  2)lacentffi  are  generally  in  close  ajipo- 
sitioi)  and  become  'fii>cd  into  a  single  mass,  the  cords,  sejiarateT}' 
attached  to  each  la'tus,  not  infrequently  uniting  shortly  before  reaching 
the  placental  mass,  their  vessels  anastomosing  freely.  '  In  other  more 
rare  instances  both  foetuses  are  contained  in  a  common  amniotic  sac; 
but  as  the  amnion  is  a  purely  fcetal  membrane,  it  is  ]irobable  that  When 
this  arrangement  is  met  with  the  originally  existing  septum  between 
the  amniotic  sacs  has  been  destroyed.  Un  both  these  latter  cases  the| 
twins  must  have  been  developed  from  a  single  ovule  containing  a| 
double  germ)  and  Schroeder  states  that  they  are  then  always  of  the' 
same  sex.  Dr.  Bruntou  ^  has  started  a  precisely  op])osite  theory,  and 
has  tried  to  prove  that  twins  of  the  same  sex  are  contained  in  se])anite 
bags  of  membrane,  while  twins  of  opposite  sexes  have  a  common  sac. 
He  says  that  out  of  25  cases  coming  under  his  observation,  in  15  the 
children  contained  in  ditferent  sacs  were  of  the  same  sex,  but  in  the 
remaining  10,  in  which  there  was  only  one  sac,  they  were  of  opjiosite 
sexes.  It  is  difficult  to  l)elieve  that  there  is  not  an  error  in  these 
observations,  since  twins  contained  in  a  single  amniotic  sjic  do  not  occur 
nearly  as  often  as  ten  times  out  of  twenty-five  cases,  and  no  distinction 
is  made  between  a  common  chorion  with  two  anuiions  and  a  single 
chorion  and  amnion.  The  facts  of  double  monstrosity  also  disprove 
this  view,  since  conjoined  twins  must  of  necessity  arise  froin  a  single 
ovule  with  a  double  germ,  and  there  is  no  instance  on  record  in  which 
they  were  of  ojiposite  sexes. 

'  Obsl.  Tram.,  vol.  xi.  p.  67. 


ABNORMAL   PREGNANCY.  173 

In  triplets  the  membranes  and  })lacentte  may  be  all  separate,  or,  as  isJ 
commonly  the  ease,  there  is  one  eomplete  ba<^  of"  membranes,  and  a] 
seeond  having  a  common  chorion  with  a  double  amnion.     It  is  prob- 
able, therefore,  that  triplets  are  generally  developed  from  two  ovules,! 
one  of  which  contains  a  double  germ. 

Diagnosis  of  Multiple  Preg-nancy. — It  is  comparatively  seldom 
that  twin  pregnancy  can  be  diagnosed  before  the  birth  of  the  first  child, 
and  even  when  suspicion  has  arisen  its  indications  ai'e  very  defective. 
There  is  generally  an  unusual  size  and  an  irregularity  of^  shajie  of  the 
uterus,  sometimes  even  a  distinct  depression  or  sulcus  between  the  two 
foetuses.  When  such  a  sulcus  exists,  it  may  be  possible  to  make  out 
parts  of  each  foetus  by  palpation  on  either  side  of  the  uterus.  The  only 
sign,  however,  on  which  the  least  reliance  can  be  placed  is  the  detection 
of  two  foetal  hearts.  If  two  distinct  pulsations  are  heard  at  different 
parts  of  the  uterus  [  if  on  carrying  the  stethoscope  from  one  point  to 
another  there  is  an  interspace  where  pulsations  are  no  longer  audible,  or 
when  they  become  feeble  and  again  increase  in  clearness  as  the  second 
point  is  reached;  and,  above  all,  if  we  are  able  to  make  out  a  difference 
in  frequency  between  them, — the  diagnosis  is  tolerably  safe.  It  must  be 
remembered,  however,  that  the  sounds  of  a  single  heart  may  be  heard 
over  a  larger  space  than  usual,  and  hence  a  possible  source  of  error. 
Twin  pregnancy,  moreover,  may  readily  exist  without  the  most  careful 
auscultation  enabling  us  to  detect  a  double  pulsation,  especially  if  one 
child  lie  in  the  dorso-posterior  position,  -when  the  body  of  the  other 
may  prevent  the  transmission  of  its  heart's  beat.  The  so-called 
placental  souffle  is  generally  too  diffuse  and  irregular  to  be  of  any 
use  in  diagnosis,  even  when  it  is  distinctly  heard  at  separate  parts 
of  the  uterus. 

Superfoetation  and  Superfecundation. — Closely  connected  with 
the  subject  of  multiple  pregnancies  are  the  conditions  known  as  super- 
fecimdation  and  superfoetation,  regarding  which  there  have  been  much 
controversy  and  difference  of  opinion. 

By  the  former  is  meant  the  fecundation,  at  or  near  the  same  periodV 
of  time,  of  two  separate  ovules  before  the  decidua  lining  the  uterus  has! 
been  formed,  which  by  many  is  supposed  to  form  an  insuperable  obsta- 
cle to  subsequent  impregnation.  The  possibility  of  this  occurrence  has 
been  incontestably  proved  by  the  class  of  cases  already  referred  to,  in 
which  the  same  woman  has  given  birth  to  twins  bearing  evident  traces 
of  being  the  ofFs])ring  of  fathers  of  different  races. 

By  siiperfcetation  is  meant  the  impregnation  of  a  second  ovule  when  1  ^^ 
the  uterus  already  contains  an  ovum  which  has  arrived  at  a  considerable  \  ' 
degree  of  development.     The  cases  which  are  supposed  to  prove  the 
possibility  of  this  occurrence  are  very  numerous.     They  are  those  in  | 
which  a  woman  is  delivered  simultaneously  of  foetuses  of  very  different|| 
ages,  one  bearing  all  the  marks  of  having  arrived  at  term,  the  other  of  I 
prematurity;  or  those  in  which  a  w'omaii  is  delivered  of  an  apparently ij 
mature  child,  and,  after  the  lapse  of  a  few  months,  of  another  equally!  i 
mature.     The  possibility  of  superfoetation  is  strongly  denied  by  many' 
practitioners  of  eminence*,  and  explanations  are  given  which  doubtless 
seem  to  account  satisfactorily  for  a  large  proportion  of  the  supposed 


174  rjiKuxAycY. 

exaiiij)les.  In  tlio  foniu'i*  class  of  cases  it  is  supposed,  with  imu-U 
j)n»l)al)ility,  that  there  is  an  ordiiiarv  twin  j)re<rnancy,  tlie  development 
of  one  f(etiis  heinj;-  I'ctai'ded  hy  the  jn'csence  in  iilrro  of  another.  That 
this  is  not  an  uncommon  occurrence  is  certain,  and  the  fact  has  alniidy 
been  alluded  to  in  treating  of  twin  pregnancy.  In  cases  of  the  latter 
kind  it  is  jiossihle  that  some  of  them  may  be  due  to  separate  impretrna- 
tiou  in  a  biiubcil, uterus,  the  contents  of  one  division  being  thrown  oil' a 
considerable  tinu;  before  those  of  the  other.  Numerous  authfiitic  exam- 
j)les  of  this  occurrence  are  recorded,  but  Ijy  far  the  most  I'cmarkable  is 
that  related  by  Dr.  Koss  of  Brighton,  which  has  been  already  referi-e<l 
to  (p.  68).  In  this  case  the  patient  had  previously  given  l>irth  to  many 
children  without  any  suspicion  of  her  abnormal  ibrmation  having  arisen, 
and,  had  it  not  been  detected  by  Dr.  Ross,  the  case  might  iairly  enough 
have  been  claimed  as  an  indubitable  exan)])le  of  suj)erf(jetatiou. 

Making  every  allowance  for  these  ex])lnnations,  there  remains  a  con- 
siderable number  of  cases  which  it  is  very  ditKcult  to  account  lor  excej)t 
on  the  supposition  that  the  second  child  has  been  conceived  a  consider- 
able time  after  the  first.  Those  interested  in  tlie  subject  will  find  a 
large  number  of  examples  collected  in  a  valuable  paper  by  Dr.  Bonnar 
of  Cu})ar.'  He  has  adopted  the  ingenious  plan  of  consulting  the  records 
of  the  British  peerage,  where  the  exact  date  of  the  birth  of  successive 
children  of  peers  is  given,  without,  of  course,  any  reasonable  possibility 
of  error,  and  he  has  collected  numerous  examples  of  births  rajiidly  suc- 
ceeding each  other  wdiich  are  apparently  inexplicable  on  any  other 
theory.  In  one  case  he  cites  a  child  was  born  September  12, 1849,  and 
the  mother  gave  birth  to  another  on  January  24,  1850,  after  an  inter- 
val of  only  127  days.  Subtracting  from  that  14  days,  which  Dr. 
Bonnar  assumes  to  be  the  earliest  possible  jieriod  at  which  a  fresh 
impregnation  can  occur  after  delivery,  we  reduce  the  gestation  to  113 
days  ;  that  is,  to  less  than  four  calendar  months.  As  both  these  chil- 
dren survived,  the  second  child  could  not  possibly  have  been  the  result 
of  a  fresh  impregnation  after  the  birth  of  the  first ;  nor  could  the  first 
child  have  been  a  twin  prematurely  delivered,  for  if  so  it  must  have  only 
reached  rather  more  than  the  fifth  mouth,  at  which  time  its  survival 
would  have  been  impossible. 

Besides  the  numerous  examples  of  cases  of  this  kind  recorded  in  most 
obstetric  works,  there  are  one  or  two  of  miscarriage  in  the  early  months, 
in  which,  in  addition  to  a  foetus  of  four  or  five  months'  growth,  a  ]>er- 
fectly  fresh  ovum  of  not  more  than  a  month's  develo|)ment  was  thrown 
off.  One  such  case  was  shown  at  the  01)Stetrical  Society  in  1862,  which 
was  reported  on  by  Drs.  Harley  and  Tamier,  who  stated  that  in  their 
opinion  it  was  an  examjile  of  superfbetation.  A  still  more  conclusive 
case  is  recorded  by  Tyler  Smith  :^  "  A  young  married  woman,  pregnant 
for  the  first  time,  miscarried  at  the  end  of  the  fifth  month,  and  some 
hours  afterward  a  small  clot  was  discharged  enclosing  a  ]H'rfectly 
healthy  ovum  of  about  one  month.  There  were  no  signs  of  a  double 
uterus  in  this  case.  The  patient  had  menstruated  reguhirly  during  the 
time  she  had  been  pregnant."  This  case  is  of  special  interest  from  the 
fact  of  the  patient  having  menstruated  during  pregnancy — a  circiim- 

1  Edin.  Med.  Jouni.,  lS()4-65.  '  Manual  of  Obstetric.^,  p.  112. 


ABNORMAL   PREGNANCY. 


175 


stance  only  explicable  on  the  same  anatomical  ^ronnds  which  render 
supcrfatation  jxwsihle.  So  far  as  I  know,  it  is  the  only  instance  in 
which  the  coincidence  of  superfaitatioii  and  menstruation  during  early 
pre<^nancy  has  been  observed. 

The  obiections  to  tlie  possibility  of  superfictation  are  based  on  the| 
assumptions  tliat  theVk^'ichia  so  completely  tills  up  the  uterine  cavity  | 
that  the  ])assage  of  the  spermatozoa  is  impossible;  that  their  passage  is| 
prevented  l)v  the^lnucous  plug  which  blocks  up  the  cervix;  and  that! 
when  impregnation  has  taken  place  t>vulation  is  suspended.     Jtis,  how-' 
ever,  certain  that  none  of  these  is  an  insuperable  obstacle  to  a  second 
impregnation.     The  first  was  originally  based  on  the  older  and  errone- 
ous view  which  considered  the  decidua  to  be  an  exudation  lining  the 
entire  uterine  cavity  and  sealing  up  the  mouths  of  the  Fallopian  tubes 
and  the  aperture  of  the  internal  os  uteri.   ^The  decidua  reHexa,  however,  \ 
does  not  come  into  apposition  with  the  decidua  vera  until  about  the 
eighth  week  of  pregnancy,  and  therefore  until  that  time  there  is  a  free 
space  between  the  two  membranes  through  which  the  spermatozoa  might    i 
pass  to  the  open  mouths  of  the  Fallopian  tube,  and  in  which  a  newly- 
impregnated  ovule  might  graft  itself.  /    A  reference  to  the  accompanying 
figure  of  a  pregnancy  in  the  third  mouth,  copied  from  Coste's  work,  will 
readily  show  that,  as  far  as  the  decidua  is  concerned,  there  is  no  mechan- 


FiG.  81. 


Illustrating  the  Cavity  between  the  Decidua  Vera  and  the  Decidua  Reflexa  during  the  early 
months  of  pregnancy.    (After  Coste.) 

ical  obstacle  to  the  descent  and  lodgment  of  another  impregnated  ovule 
(Fig.  81).  Then,  as  regards  the  plug  of  mucus,  it  is  pretty  certain  that 
this  is  in  no  way  different  from  the  mucus  filling  the  cervix  in  the  non- 
pregnant state,  which  offers  no  obstacle  at  all  to  the  passage  of  the  sper- 


176  PREGNANCY. 

nmtozoa.  '  Lastly,  rcspoftinj^tlu'  ccssntion  of  ovulation  (liiriiij;  prcjjfnaiu'y, 
this,  no  doubt,  is  tlu'  rule,  and  prohaltly  satisllu-torily  ('Xj)lains  the  rarity 
of  supertcetation.  \  riiore  are,  lu)\vevt'r,  a  sutticicnt  number  of  aullicnti- 
cated  cases  of  menstruation  during  pregnancy  to  prove  that  ovulati<tn 
is  not  always  absolutely  in  abeyance^  and  as  long  as  it  occurs  then-  is 
unquestionably  no  })ositive  mechanical  obstruction,  at  least  in  the  eailv 
months  of  pregnancy,  in  the  way  of  the  inipi'cgnation  and  lodgment  of 
the  ovules  that  are  thrown  off.  The  reasonable  conclusion,  therefore, 
seems  to  be  that,  although  a  large  majority  of  the  su})po.«ed  cases  are 
explicable  iu  other  ways,  it  cainiot  be  admitted  that  superfa?tation  is 
either  ])hysically  or  mechanically  impossible. 

Extra-uterine  Pregnancy. — The  most  important  of  the  al^normal 
varieties  of  })regnancy,  if  Ave  consider  the  serious  and  very  generally 
fatal  results  attending  it,  is  the  so-called  exfra-uterine  fadation,  Mhich 
consists  in  the  arrest  and  development  of  the  ovum  outside  the  cavity 
of  th£  uterus.  Of  late  years  this  subject  has  received  much  Mell-meritcd 
attention,  which,  it  is  to  be  hoped,  may  lead  to  the  establishment  of  .some 
definite  rules  for  the  management  of  this  most  anxious  and  dangerous 
class  of  cases. 

Site  of  Extra-uterine  Pregnancy. — The  ovum  may  be  arrested  and 
developed  in  various  situations  on  its  way  to  the  uterus,  most  commonly 
in  some  part  of  the  Fallopian  tube,  or  it  may  be  in  the  cavity  of  the 
abdomen,  or  even  quite  beyond  it,  as  in  a  few  rare  ca.ses  in  'which  the 
ovum  has  found   its  way  into  a  hernial  sac. 

Extra-uterine  gestation  may  be  subdivid(>d  into  the  following  da-sses  : 
1st,  and  most  common  of  all,  tvhal  gestation,  and  as  varieties  of  this, 
although  by  .some  made  into  distinct  cla.sses,  [a)  interstitial,  {b)  tubo-ovn- 
I'ian  gestation,  and  (c)  sub^igjtonegs^iclvic  or  intra-Ugamentous.  /In  the 
first  of  these  subdivisions  the  ovum  is  arrested  in  the  part  of  the  Fallo- 
pian tube  that  is  situated  in  the  substance  of  the  uterine  parietesi  in  the 
second, l.lat  or  near  the  fimbriated  extremity  of  the  tube,  so  that  jtart  of 
its  cyst  is  formed  l)v  the  tube  and  part  by  the  ovary 'j|  in  the  third,  an 
originally  tubal  pregnancy  develops  into  the  broad  ligament,  ancT  con- 
tinues this  development  beneath  the  peritoneum  of  the  pelvic  floor\\'  The 
occurrence  of  this  variety  has  been  conclusively  demonstrated  by  Hart 
and  Carter.'  2d.  Ahdominal  gestation,  in  which  an  ovum,  instead  of 
finding  its  way  into  tlie  tube,{[ialls  into  the  peritoneal  cavity,  and  there 
becomes  attached  and  developed |;\  or  the  so-called \Becond a ry  abdominal 
gestation,  in  which  an  extra-uterine  pregnancy,  originally  tubal, 
becomes  ventral  through  rupture  of  its  cysts  and  escape  of  its  contents 
into  the  abdominal  cavityji;  (^r  in  which  an  intra-ligamentous  pregnancy 
continues  to  develop  until  it  lifts  up  the  abdominal  peritoneum  and 
forms  a  purely  extra-peritoneal  variety  of  abdominal  gestation.  This 
has  been  called  by  Hart  and  Carter  subperitoneo-abdominal.  .3d.  (/ra- 
riwi  gestation,  the  existence  of  whicii  is  denied  by  many  writers  of  emi- 
nence, such  as  Velpeau  and  Arthur  Farre,  while  it  is  maintained  by 
others  of  equal  celebrity,  such  as  Kiwisch,  Coste,  and  Hecker.  It  nuist 
be  admitted  that  it  is  extremely  difficult  to  understand  how  an  ovarian 
pregnancy,  in  the  strict  sense  of  the  word,  can  occur,  for  it  implies  that 

*  Sectional  Anatomy  oj  Advanceil  Extm-uterine  Gestation,  Edin.,  1887. 


ABNORMAL  PREGNANCY.  177 

the  ovule  has  become  imjiregiuited  before  the  laceration  of  the  Graafian 
follicle,  through  the  coat.s  of  which  the  spermatozoa  must  have  passed. 
Coste,  indeed,  believes  that  this  frequently  happens ;  but,  while  sper- 
matozoa have  been  detected  on  the  surface  of  the  ovary,  their  penetra- 
tion into  the  Graafian  follicle  has  never  been  demonstrated.  Farre  has 
also  clearly  shown  that  in  many  cases  of  su})posed  ovarian  ])rcgnancy 
the  surrounding  structures  were  so  altered  that  it  was  impossible  to  trace 
their  exact  origin  and  to  say  to  a  certainty  that  the  foetus  was  really 
within  the  substance  of  the  ovary.  ( Kiwisch  gives  a  reasonable  expla- 
nation of  tiiese  cases  by  supposing  that  sometimes  the  Graafian  follicle 
may  rupture,  but  that  the  ovule  may  remain  within  it  without  being 
discliarged.^  Through  the  rent  in  the  walls  of  the  follicle  the  spermato- 
zoa may  reach  and  impregnate  the  ovule,  which  may  develop  in  the  situ- 
ation in  which  it  has  been  detained.  The  subject  has  recently  been  ably 
considered  by  Puech,'^  who  admits  two  varieties  of  ovarian  pregnancy, 
according  as  the  foetus  has  developed  in  a  vesicle  which  has  remained 
open  or  in  one  which  has  closed  immediately  after  fecundation.  He 
considers  that  most  cases  of  so-called  ovarian  pregnancy  are  either  der- 
moid cysts,  ovario-tubal  pregnancies,  or  abdominal  pregnancies  in  which 
the  placenta  is  attached  to  the  ovary,  and  that  even  in  the  rare  cases  of 
true  ovarian  pregnancies  the  progress  and  results  do  not  differ  from  that 
of  abdominal  pregnancy.  (While,  therefore,  it  is  impossible  to  deny  the 
existence  of  ovarian  pregnancy,  it  must  be  considered  to  be  a  very  rare  \  ] 
and  exceptional  variety,  the  existence  of  which  has  never  been  actually  J ' 
proved;  which,  as  far  as  treatment  and  results  are  concerned,  does  not/ ' 
differ  from  tubular  or  abdominal  gestation.  ]  4th.  There  are  two  rare 
varieties  in  which  an  ovum  is_  developed  eitner  in  the  supplementary 
horn  of  a  bilobed  uterus  or  in  a  hernial  sac. 

For  the  sake  of  clearness  we  may  place  these  varieties  of  extra-ute- 
rine gestation  in  the  following  tabular  form  : 

1st.   Tubal— 
fj  (a)  Insterstitial,  (6)    Tubo-ovarian,  (c)    Subjjeritoneo-pelvic. 

2d.  Abdominal — 

{a)  Primary,  (b)  Secondary. 

3d.    Ovarian. 

4th.  In  bilobed  uterus,  hernial,  etc. 

Causes. — The  etiology  of  extra-uterine  foetation  in  any  individual 
case  must  necessarily  be  almost  always  obscure.  (  Broadly  speaking,  it 
may  be  said  that  extra-uterine  foetation  may  be  produced  by  any  condi- 
tion which  prevents  or  renders  difficult  the  passage  of  the  ovule  to  the 
uterus,  while  it  does  not  prevent  the  access  of  the  spermatozoa  to  the 
ovule,  j  Thus,  inflammatory  thickening  of  the  coats  of  the  Fallopian 
tubes  Dy  lessening  their  calibre,  but  not  sufficiently  so  as  to  prevent 
the  passage  of  the  spermatozoa,  may  interfere  Avith  the  movements  of 
the  tube  which  propel  the  ovum  forward,  and  so  cause  its  arrest.  A 
similar  effect  may  be  produced  by  various  morbid  conditions,  such  as 
inflammatory  adhesions,  from  old-standing  peritonitis,  pressing  on  the 
tube  ;  obstruction  of  its  calibre  by  inspissated  mucus  di'  small  poly- 
poid growths ;  the  pressure  of  uterine  or  other  tumors,  and  the  like. 

1  Anal,  de  Gyncc,  1878,  toin.  x.  p.  102. 
12 


17S  PRKG  NANCY. 

The  I'act  that  oxtra-iiteriiie  prcgiiaiuics  (uiiir  most  frequently  in  imil- 
tipaiU'.  and  coniiiaiativcly  nuvly  in  women  under  thirty  yeai-s  of  age, 
tends  to  show  that  these  oontlitions,  which  are  clearly  ni<jre  likely  to 
be  met  with  in  such  women  than  in  young  jirimijtaije,  have  consid- 
erable influence  in  their  causation.  A  curiously  large  )>rojtortion  of 
eases  occur  in  wonu'U  who  have  either  been  ])reviouslv  altogether 
sterile  or  in  whom  a  lonir  interval  of  time  has  elapsed  since  their 
last  pregnancy.  The  disturbing  effects  of  fright,  either  during  coition 
or  a  few  chiys  afterward,  have  been  insisted  on  by  many  authoi"S  as 
a  ])ossible  cause.     Numerous   cases    of  this    kind    are    recorded,  and, 

j  although  the  influence  of  emotion  in  the  production  of  this  condi- 
tion is  not  susceptible  of  proof,  it  is  not  difficult  to  imagine  that 
spasms  of  the  Fallopian  tubes  might  be  produced  in  *.his  way  which 
Avould  either  interfere  with   the  passage  of  the  ovum  or  direct  it  into 

\  the  abdominal  cavity.  The  occurrence  of  abdominal  pregnancy  is 
probably  less  difficult  to  account  for  if  we  admit,  Mith  Coste,  that 
the  ovule  becomes  impregnated  on  the  surface  of  the  ovary  itself, 
lor  there  must  be  very  many  conditions  which  prevent  the  j)ro])er  adaj)- 
tation  of  the  fimbriated  extremity  of  the  tube  to  the  suriace  ol"  the 
ovary,  and,  failing  this,  the  ovum  must  of  necessity  drop  into  the 
abdominal  cavity.  Kiwisch  has  pointed  out  that  this  is  ])articularly 
apt  to  occur  when  the  Graafian  follicle  develops  on  the  posterior  sur- 
face of  the  ovary  ;  and,  indeed,  it  is  probable  that  it  may  be  of  com- 
mon occurrence,  and  that  the  comparative  rarity  of  abdcmiinal  preg- 
nancy is  due  to  the  difficulty  with  which  the  impregnated  ovule 
engrafts  itself  on  the  surrounding  viscera.  Imj)regnation  may  act- 
ually occur  in  the  abdominal  cavity  itself,  of  M'hich  Keller  *  relates  a 
remarkable  instance.  In  this  case  Koebcrle  had  removed  the  body 
of  the  uterus  and  part  of  the  cervix,  leaving  the  ovaries.  In  the 
portion  of  the  cervix  that  remained  there  was  a  fistulous  ajierture 
opening  into  the  abdominal  cavity,  through  which  semen  passed  and 
pn)duced  an  abdominal  gestation.  Several  curious  cases  are  also 
recorded,  which  have  given  rise  to  a  good  deal  of  discussion,  in  which 
a  tubal  pregnancy  existed  while  the  corpus  luteum  was  on  the  oj^jio- 
site  side  (Fig.  82).  The  most  probable  explanation,  however,  is  that 
the  fimbriated  extremity  of  the  tube  in  Avhich  the  ovum  was  found 
had  twisted  across  the  abdominal  cavity  and  gra.sped  the  ojijiosite 
ovary,  in  this  way  perhaps  producing  a  flexion  Avhich  impeded  the 
jirogre&s  of  the  ovum  it  luid  received  into  its  canal.  Tyler  Smith 
suggested  that  such  cases  might  be  explained  by  supp(»siiig  that  the 
ovum,  after  reaching  the  uterus,  failed  to  graft  itself  in  the  mucous 
jn(  inbrane,  but  found  its  way  into  the  (t]>])osite  Fallopian  tube.  Kuss- 
maid-  thinks  that  such  a  passage  of  the  ovum  across  the  tUerine  cav- 
ity may  be  caused  by  muscular  contraction  of  the  uterus  occurring 
shortly  after  conception,  squeezing  the  yet  free  ovum  up^vard  toward 
the  opening  of  the  o]>]iosite  tube,  and  possibly  into  the  tube  itself. 

The  history  and  progress    of  cases  of  extra-uterine  ])regnan(y  arc 
materially  different  according  to  their  site,  and  for  practical  ])urj)(>ses 

'  De.H  Grosd'e.tses  exira-uterine.%  Paris,  1872. 
^Mon.f.  Ocburt.,  1S62,  Bd.  xx.  S.  L'95. 


ABXORMA  L    PREGNANCY. 


179 


we  may  consider  them  as  fonniii^  two  great  classes,  the  tubal  (with 
its  varieties)  aiul  the  abdominal. 

Tubal  Pregnancies. — When  the  ovum  is  arrested  in  any  part  of 
the  Fallopian  tul)e  the  chorion  soon  commences  to  develop  villi,  just 
as  in  ordinary  j)re<;'nancy,  which  engraft  themselves  into  the  mucous 
lining    of   the    tube    and   fix   the   ovum    in    its  new    position.     The 

Fig.  82. 


Tubal  Pregnancy,  with  the  Corpus  Luteum  in  the  Ovary  of  the  Opposite  Side. 
The  decidua  is  represented  iu  the  process  of  detacliment  from  the  uterine  cavity. 


mucous  membrane  becomes  hypertrophied.  much  in  the  same  way  as 
that  of  the  uterus  under  similar  circumstances,  so  that  it  becomes 
developed  iuto  a  sort  of  pseudo-decidua,  the  uterine  extremity  of  which 
has  been  observed  to  be  open  and  in  communication  with  the  lining 
membrane  of  the  uterus.^  Inasmuch,  however,  as  the  mucous  coat 
of  the  tubes  is  not  furnished  with  tubular  glands,  a  true  decidua  can 
scarcely  be  said  to  exist  :■  nor  is  there  any  growth  of  membrane  around 
the  ovum  analogous  to  the  decidua  reflexay  The  ovum  is,  therefore, 
comparatively  speaking,  loosely  attached  to  its  abnormal  situation, 
and  hence  hemorrhage  from  laceration  of  the  chorion  villi  can  very 
readily  take  place. 

It  is  seldom  that  any  development  of  the  chorion  villi  into  distinct 
placental  structure  is  observed  |  this  is  probably  owing  to  the  fact  that 
laceration  and  death  generally  occur  before  the  period  at  which  the 
placenta  is  normally  formed.      The  muscular  coat  of  the  tube  soon\ 
becomes   hypertrophied,  and  as  the  size  of  the  ovum  increases   the  \ 
fibres  are  sej^arated  from  each  other,  so  that  the  ovum  protrudes  at  I 
certain  points  through  them,   and  at  these  it  is  only  covered  by  the 
stretched  and  attenuated  mucous  and  peritoneal  coats  of  the  tube.     At 
this  time  the  tubal  pregnancy  forms  a  smooth  oval  tumor,  which,  as  a 
rule,  has  not  formed  any  adhesions  to  the  surrounding  structures  (Fig. 
83).     The  part  of  the  tube  unoccupied  by  the  ovum  may  be  found  un- 
altered, and  permeable  in  both  directions,  or,  more  frequently,  it  becomes 
so  stretched  and  altered  that  its  canal  cannot  be  detected.     Most  fre- 
quently it  is  that  part  of  the  tube  nearest  the  uterus  which  cannot  be 

'  L.  Bandi,  BiUrolIt's  HamJbuch  dcr  Frauenkronkheilcn. 


180 


PB  EG  NANCY. 


inadi'  out.     The  coiKlitioii  of  the  uterus  iu  this  a.s  in  other  forms  of 

■   extra-uterine  j)rei;naneyTias  I)eeu  the  sulyeet  of  eonsiderahle  diseussion. 

|(lt  is  now  universally  adniitted   that  the  uterus  undergoes  a  certain 

amount  of  svmpathetie  eii'^or^ement,  the  cervix  becomes  softened  as  in 

natural  pregnancy,  and  the  nuicous  meiubrane  develops  into  a  true 


Fig 


Tubal  Pregnancy.    (From  a  specimen  in  the  Museum  of  King's  College.) 

decidual  In  many  cases  the  decidua  is  found  on  post-mortem  examina- 
tion, in  others  it  is  not,  and  hence  the  donl)ts  that  some  have  expressed 
as  to  its  existence.  The  most  reasonable  ex]>lanation  of  its  absence  is 
that  given  by  Duguet,^  who  has  sho\vn  that  \t,  is  f^n'  from  ^incnmmon  for 
the  uterino  dcfidun  to  l)o  thrown  off  ni  vinssr  durinir  the  hemorrhagic 
dischargi'-  wlii'li-o  rrcipK'iitly  piXTcilc  tlic  fatal  i-sue  of  extra-uteriue 
gestation. 

Interstitial  and  False  Ovarian  Pregnancy. — When  the  ovum  is 
arrested  in  that  portion  of  the  tube  passing  through  the  uterus  in  so- 
called  interstitial  ]n-egnancy,  the  muscular  fibres  of  the  uterus  become 
stretched  and  distended  and  form  the  outer  covering  of  the  ovum. 
When,  on  the  other  hand,  the  site  of  arrest  is  in  the  fimbriated  ex- 
tremity of  the  tube,  the  containing  cyst  is  formed  partly  of  the  fimbriji? 
of  the  tube,  partly  of  ovarian  tissue;  hence  it  is  much  more  distcnsiljle, 
and  the  pregnancy  may  continue  Avithout  laceration  to  a  more  advanced 
period,  or  even  to  term,  so  that  when  the  ovum  is  placed  in  this  situa- 
tion the  case  mucli  more  nearly  resembles  one  of  abdominal  pregnancy. 

Progress  and  Termination. — The  termination  of  tubal  pregnancy 
ill  tlie  immense  majority  of  cases  is  death,  ])roduced  by  laceration  giving 
rise  cither  to  interjiaLijemorrhage  or  to  subsequent  intense  peritonitis. 
Rupture  usually  occurs  at  au  early  period  of  pregnancy,  most  generally 

*  Annales  de  Gynecolofjie,  1874,  torn.  i.  p.  269. 


ABNORMAL  PREGNANCY.  181 

from  the  fourtli  to  tlio  twelf'lli  week,  rarely  later.  However,  a  few  in- 
stances are  recorded  in  which  it  did  not  take  place  until  the  fourth  or 
fifth  month,  and  8axtorj)h  and  Spicgclberg  have  recorded  api)arently 
authentic  cases  in  which  the  pregnancy  advanced  to  term  without 
laceration :  these  were,  however,  ])robably  examples  of  the  subpcri- 
toneo-pelvic  or  abdominal  varieties.  It  is  generally  effected  by  dis- 
tension of  the  tube,  Avhich  at  last  yields  at  the  point  which  is  most 
stretched ;  and  sometimes  it  seems  to  be  hastened  or  determined  by 
accidental  circumstances,  such  as  a  blow  or  fall  or  the  excitement  of 
sexual  intercourse. 

Symptoms  of  Rupture. — The  symptoms  accompanying  rupture  are 
those  of  intense  collapse,  often  associated  with  severe  abdominal  paiu^ 
produced  by  the  laceration  of  the  cyst.  The  patient  will  be  found 
deadly  pale,  with  a  small,  thready,  and  almost  imperceptible  pulse, 
perhaps  vomiting,  but  with  mental  faculties  clear.  If  the  hemor- 
rhage be  considerable  she  may  die  without  any  attempt  at  reaction. 
Sometimes,  however — and  this  generally  occurs  in  cases  iu  which  the 
tube  tears,  the  ovum  remaining  intact — the  hemorrhage  may  cease  on,, 
account  of  the  ovum  protruding  through  the  aperture  and  acting  as  a'i( 
plug.  The  patient  may  then  imperfectly  rally,  to  be  again  prostrated 
by  a  second  escape  of  blood,  which  proves  fatal.  If  the  loss  of  blood 
is  not  of  itself  sufficient  to  cause  death  from  shock  and  ausemia,  the 
fatal  issue  is  generally  only  postponed,  for  the  effused  blood  soon  sets 
up  a  violent  general  peritonitis,  which  rapidly  carries  off  the  patient. 
If  she  should  survive  the  second  danger,  the  case  is  transformed  into 
one  of  abdominal  pregnancy,  the  foetus  becoming  surrounded  by  a 
capsule  produced  by  inflammatory  exudation  (Fig.  84).  The  case  is 
then  subjected  to  the  rules  of  treatment  presently  to  be  discussed  when 
considering  that  variety  of  extra-uterine  gestation. 

Diagnosis. — The  possibility  of  diagnosing  tubal  gestation  before 
rupture  occurs  is  a  question  of  great  and  increasing  interest,  from 
the  fact  that  could  its  existence  be  ascertained  we  might  very  fairly 
hope  to  avert  the  almost  certainly  fatal  issue  which  is  awaiting  the 
patient.  Unfortunately,  the  symptoms  of  tul^al  pregnancy  are  always 
obscure,  and  too  often  death  occurs  without  the  slightest  suspicion  as 
to. the  nature  of  the  case  having  arisen.  ((In  the  first  place,  it  is  to  be 
observed  that  all  the  usual  sympathetic  disturbances  of  pregnancy  exist : 
the  breasts  enlarge,  the  areolae  darken,  and  morning  sickness  is  ])rescnt. 
/There  is  also  an  arrest  of  menstruation,  but  after  the  absence  of  one) 
V)r  more  periods  there  is  often  an  irreirular  hemorrhacric  discharge.  This 
is  an  important  symptom,  the  value  of  which  in  indicating  the  existence 
of  tubal  pregnancy  has  of  late  years  been  much  dwelt  upon  by  various 
authors,  both  in  this  country  and  abroad.  Barnes  attributes  it  to  partial 
detachment  of  the  chorion  villi,  produced  by  the  ovum  growing  out  of 
proportion  to  the  tube  in  which  it  is  contained.  AVhethcr  this  is  the 
correct  explanation  or  not,  it  is  a  fact  that  irregular  hemorrhage  very 
generally  precedes  the  laceration  for  several  days  or  more.  (Associated 
with  the  hemorrhage  there  may  occasionally  be  found  shre(^s  of  the 
decidual  lining  of  the  uterus,  the  presence  of  which  would  materially 
aid   the  diagnosis.     Aceunipanying   this   hemorrhage    there  is  almost 


182 


mix;  NANCY. 


always  more  or  lc.<?s  alxloniinal  pain,  prodiicod  hy  the  strctchiiMr  of 
the  tissue>r7irTvl)i(irTri('"'u\HriiTT:^'j71a(-<'(l,  and  this  is  sometimes  de- 
seribed  as  beiii^  of  very  intense  and  crampy  eljaraeter.  \i\  then,  we 
meet  with  a  ease  in  which  the  symptoms  of  early  pregnancy  exi>t,  in 
wliich  then;  are  irregidar  h)sses  of  Mood,  possibly  discharge  of  mem- 


Kk;.  84. 


Extra-uterine  Pregnancy  at  Term  of  the  Tubo-ovarian  X'arioty.    (After  a  case  of  Dr.  A.  Sibley 
Campbell's,  of  Augusta,  Georgia!) 

branous  shreds,  and  abdominal  ])ain,  a  careful  examination  should  be 
insisted  on,  and  then  the  true  nature  of  the  ease  may  jiossibly  he 
ascertained.  Should  extra-uterine  fa:'tation  exist,  we  should  cx])ect 
to  find  the  uterus  somewhat  enlarged  and  the  cervix  soitened,  as  in 
early  jiregnancy,  but  both  these  chaugcs  are  doubtless  generally  less 
marked  than  in  normal  pregnancy.  This  fact  of  itself,  however,  is 
of  little  diagnostic  value,  for  slight  difrerenccs  of  this  kind  must  always 
be  too  indefinite  to  justify  a  positive  o})inioii. 

(  The  existence  of  a  periuterine  tumor,  rounded  or  oval  in  outline,  and 
producing  more  or  less  displacement  of  the  uterus,  in  the  direction  ojipo- 
site  to  that  in  Avhich  the  tumor  is  situated,  may  jioint  to  the  existence  of 
tubular  lVetatif)n.'\  By  bimanual  examination,  one  hand  depressing  tiie 
abdominal  wall,^vhile  the  examining  finger  of  the  other  acts  in  concert 
with  it  either  through  the  vagina  or  rectum,  the  size  and  relations  of 
the  growth  may  be  made  out.     There  are  various  conditions  which  give 


ABNORMAL  PREGNANCY.  \H3 

rise  to  very  similar  piiysicul  signs,  sucli  as  small  ovarian  or  fibroid 
growths,  or  the  effusion  of  blood  around  the  uterus  ;  and  the  differen- 
tial diagn(^sis  must  always  he  very  diffieult,  and  often  impossible.  A 
curious  example  of  the  diiheulty  of  diagnosis  is  reeordcd  by  Joulin,  in 
which  Huguier  and  six  or  seven  of  the;  most  skilled  obstetricians  of 
Paris  agreed  on  the  existence  of  extra-uterine  pregnane}',  and  liad,  in 
consultation,  sanctioned  an  operation,  when  the  case  terminated  by  abor- 
tion, and  proved  to  be  a  natural  pregnancy.  The  use  of  the  uterineli 
sound,  which  might  aid  in  clearing  up  the  case,  is  necessarily  contra-; 
indicated  unless  uterine  gestation  is  certainly  disproved.  Hence  it  must' 
be  admitted  that  positive  diagnosis  must  always  be  very  difficult.  So 
that  the  most  we  can  say  is,  that  when  the  general  signs  of  early  preg- 
nancy are  present,  associated  with  the  other  symptoms  and  signs  alluded 
to,  the  suspicion  of  tubal  pregnancy  may  be  sufficiently  strong  to  justify 
us  in  taking  such  action  as  may  possibly  spare  the  patient  the  necessary 
fatal  consequence  of  rupture. 

Treatment. — If  the  diagnosis  were  quite  certain,  the  removal  of  the  \ 
entire  Fallopian  tube  and  its  contents  by  abdominal  section  would  be  j 
quite  justifiable,  and  probably  would  neither  be  more  difficult  nor  more, 
dangerous  than  ovariotomy^  for  at  this  stage  of  extra-uterine  foetation 
there  are  no  adhesions  to  complicate  the  operation.     As  yet,  however, 
the  uncertainty  of  the  diagnosis  has  prevented  the   adoption  of  the 
practice. 

Dr.  T.  Gaillard  Thomas  of  New  York  ^  has  recorded  a  most  instruc- 
tive case  in  which  he  saved  the  life  of  the  patient  by  a  bold  and  judici- 
ous operation.  The  nature  of  the  case  was  rendered  pretty  evident  by 
the  signs  above  described,  ancf  Thomas  opened  the  cyst  from  the  vagina 
by  a  platinum  knife  rendered  incandescent  by  a  galvano-caustic  batterv, 
by  which  means  he  hoped  to  prevent  hemorrhage.  Through  the  open- 
ing thus  made  he  removed  the  foetus. ;  In  subsequently  attempting  to 
remove  the  placenta  very  violent  hemorrhage  took  place,  which  was  only 
arrested  by  injecting  the  cyst  M'ith  a  solution  of  persulphate  of  iron. 
The  remains  of  the  placenta  subsequently  came  away  piecemeal  after  an 
attack  of  septicperaia,  which  was  kept  in  bounds  by  freely  washing  out 
the  cyst  with  antiseptic  lotion,  the  patient  eventually  recovering.  If  I 
might  venture  to  make  a  criticism  on  a  case  followed  by  so  brilliant  a 
success,  it  would  be  that  in  another  instance  of  this  kind  it  would  be 
safer  to  follow  the  rule  so  strictly  laid  down  with  regard  to  gastrotomv 
in  abdominal  jiregnancies,  and  leave  the  placenta  untouched,  trusting  to 
the  injection  of  antiseptics  and  the  thorough  drainage  of  the  cvst  to 
prevent  mischief. 

[In  a  second  operation,  performed  by  Prof.  Thomas  on  May  10, 
1876,  in  a  ease  Avhere  the  foetus  had  been  some  time  dead,  he  incised  the 
abdomen  through  the  linea  alba,  and  extracted  a  foetus  weighing  nearlv 
seven  pounds.  The  cord  was  cut  off  at  its  origin,  and  the  wound  closed 
except  at  its  lower  angle,  where  a  drainage-tube  was  inserted.  The  ]ila- 
centa  was  removed  in  the  middle  of  the  fourth  week,  and  the  patient 
made  a  good  recovery.  Dr.  Thomas  has  had  several  similar  cases  and 
results.  This  plan  of  non-interference  with  the  placenta  in  the  same 
^  New  York  Med.  Journ.,  1875,  vol.  xxi.  p.  561. 


184  rJiEayAycY. 

cliaractcr  of  caffos  was  first  tried  in  New  York  City  about  ninety  years 
ap;o  by  Dr.  ]Mc'Kni<^iit,  and  the  woman  reeovored.  lie  liad  intended 
to  })eel  oil"  the  placenta,  but,  fortunately,  the  cord  was  broken  otf  in  the 
oj)eration,  and  lie  could  not  (ind  it  ;  hence  the  resuh.  Thus  was  estal)- 
lisiied  the  vahie  of  the  method,  although  it  was  not  generally  known 
until  quite  recently. — Kd.] 

Means  of  Destroying  the  Vitality  of  the  FcBtus. — Another  mode 
of  manaiiino-  these  cases  is  to  destroy  the  fa'tus,  so  as  to  check  its  fur- 
ther growth,  in  the  hope  that  it  may  remain  inert  and  passive  within  its 
stie.  Various  o})erations  have  been  suggested  and  practised  tor  thisj)ur- 
pose.  Thus,  needles  have  been  introduced  into  the  tumor,  through 
which  currents  of  electricity  have  been  ])assed,  cither  the  continuous 
current  or,  as  has  been  suggested  by  Duchenne,  a  si)ark  of  franklinic 
electricity.  Hicks,  Allen,  and  others  have  endeavored  to  destroy  the 
fa'tus  by  passing  an  electro-magnetic  current  through  it  by  means  of  a 
needle.  [Dr.  Allen  did  not  resort  to  galvano-]iuncture  in  any  one  of 
his  three  cases. — Ed.]  Many  successful  cases  have  followed  the  use  of 
the  faradic  current,  one  pole  being  passed  through  the  rectum  or  vagina 
to  the  site  of  the  ovum,  the  other  being  placed  on  a  point  in  the  abdom- 
inal wall  two  or  three  inches  above  Poupart's  ligament ;  or  Apostoli's 
vaginal  electrode,  in  which  both  poles  are  combined,  might  be  used. 
The  current  shoidd  be  passed  daily  for  at  least  ten  minutes,  and  con- 
tinued for  a  M'eek  or  two  until  the  shrinking  of  the  tumor  gives  satis- 
factory evidence  of  the  death  of  the  foetus.  This  practice  is  per- 
fectly safe,  and  there  can  be  no  rational  objection  to  its  being  tried. 
Aveling  makes  the  reasonable  suggestion  that  the  ciu'rcnt  acts  by 
producing  "  tetanic  contractions  of  the  ftetal  heart  due  to  the  re])eat- 
edly  broken  current  of  an  induction  machine."  ^  Sim])le  ])uncture  of 
the  cyst  has  been  successfully  practised  on  several  occasions,  either 
with  a  small  trocar  and  canula  or  with  a  simple  needle.  A  very 
interesting  case,  in  which  the  development  of  a  two  months'  tubal 
gestation  was  arrested  in  this  way,  is  recorded  by  Greenhalgh,^  and 
another  by  Martin  of  ]>crlin.^  Joulin  suggested  that  not  only  shoidd 
the  cyst  be  punctured,  but  that  a  solution  of  morphia  should  be  injected 
into  it,  which  by  its  toxic  influence  would  ensure  the  destruction  of  the 
foetus ;  and  tins  is  probably  one  of  the  best  means  at  our  disposal  of 
destroying  the  foetus.  Other  means  jn-oposed  for  effecting  the  same 
object,  such  as  pressure  or  the  administration  of  toxic  remedies  by  the 
mouth,  are  far  too  uncertain  to  be  relied  on.  vThe  simj^lest  and  most 
eirectual  })lan  would  be  to  iiitrodiK-e  the  iicedjc()f  an  aspirator,  by 
Avhich  the  liquor  amnii  would  be  drawn  off  and  the  further  growth  of 
the  foetus  eflcctually  prevented,  i  Parry,^  indeed,  is  opposed  to  this 
practice,  and  has  collected  several  cases  in  which  the  puncture  of  the 
cyst  was  followed  by  fatal  results,  either  from  hemorrhage  or  sejitica^- 
niia.  In  these,  however,  an  ordinary  trocar  and  canula  were  ])robably 
employed,  which  would  necessarily  admit   air  into    the   sac     [Toxic 

'■'The  Diagnosis  and  Electrical  Treatment  of  Earlv  Extra-uterine  Gestation," 
Brit.  Gyn.  Joiirn.,  1888-89,  vol.  iv.  p.  24. 

2  Lnncel,  1867.  ^  Monal.  f.  G\6«W.,  1868,  Bd.  xxxii.  S.  140. 

*  Parry  on  Extra-Uterine  Pregnancy,  p.  204. 


ABNORMAL  PREGNANCY.  185 

injections,  even  with  asi)inition,  arc  very  dan<^erous  as  foeticidal  expe- 
dients, and  the  results  of  experiments  reported  do  not  reeonunend  their 
adoption. — Ed.]  It  is  difficult  to  imagine  that  a  fine  hair-like  asj)ira- 
ting  needle,  rendered  perfectly  aseptic  by  carbolic  acid,  could  have  any 
injurious  results ;  and  it  could  do  no  harm,  even  if  an  error  of  diagno- 
sis had  been  made  and  the  suspected  extra-uterine  foetation  turned  out 
to  be  some  other  sort  of  growth.  If  the  aspirator  jiroves  that  an  extra- 
uterine foetation  exists,  then,  if  the  cyst  be  of  any  considcral)le  size  and 
the  pregnancy  advanced  beyond  the  second  month,  we  might,  if  deemed 
advisable,  resort  to  a  more  radical  operation,  such  as  that  so  successfully 
practised  by  Thomas. 

Treatment  when  Rupture  has  Occurred. — AVhen  the  chance  of 
arresting  the  growth  of  a  tubular  foetation  has  never  arisen,  and  we  first 
recognize  its  existence  after  laceration  has  occurred  and  the  patient  is 
collapsed  from  hemorrhage,  what  course  are  we  to  pursue  ?  Hitherto, 
all  that  has  generally  been  done  is  to  attempt  to  rally  the  patient  by 
stimulants,  and,  in  the  unlikely  event  of  her  surviving  the  immediate 
effects  of  laceration,  endeavoring  to  control  the  subsequent  peritonitis,  in 
the  hope  that  the  effused  blood  may  become  absorbed,  as  in  pelvic  hsem- 
atocele.  This  is,  indeed,  a  frail  reed  to  rest  upon,  and  when  laceration 
of  a  tubal  gestation,  advanced  beyond  a  mouth,  has  occurred,  death 
has  been  the  most  certain  result.  It  is  supposed  by  Bernutz — and  his 
opinion  is  shared  by  Barnes — that  rupture  which  does  not  prove  fatal  is 
probably  not  very  rare  in  the  first  few  days  of  extra-uterine  gestation, 
and  that  it  is  not  an  uncommon  cause  of  certain  forms  of  pelvic  h^em- 
atocele.  [Unquestionably,  the  proper  course  to  pursue  when  laceration 
has  occurred  is  to  perform  gastrotomy,  to  sponge  away  the  effused  blood, 
and  to  place  a  ligature  around  the  lacerated  tube  and  remove  it  with  its 
contents.\  This  is  no  doubt  a  bold  and  heroic  procedure,  but  no  one  who 
is  acquainted  with  the  triumphs  of  modern  abdominal  surgery  can  say 
that  it  would  be  either  impossible  or  hopeless.  The  sponging  out  of 
effused  blood  from  the  abdominal  cavity  is  an  everv-day  procedure  in 
ovariotomy,  nor  is  there  any  apparent  difficulty  in  ligaturing  and 
removing  the  sac  of  the  extra-uterine  pregnancy,  for,  as  a  rule,  there 
are  no  adhesions  formed  to  the  surrounding  parts.  The  history  of 
these  cases  shows  that  death  does  not  generally  follow  rupture  for 
some  hours,  so  that  there  would  be  usually  time  for  the  operation, 
and  the  extreme  prostration  might  be,  perhaps,  temporarily  counter- 
acted by  transfusion.  Pressure  on  the  abdominal  aorta,  resorted  to 
when  the  patient  is  first  seen,  might  possibly  be  employed  with  advan- 
tage to  check  further  hemorrhage  until  the  question  of  operation  is 
decided.  We  must  remember  that  the  alternative  is  death,  and  hence 
any  operation  which  would  afford  the  slightest  ho])e  of  success  would 
be  perfectly  justifiable.  INIr.  Lawson  Tait  and  others  have  on  many 
occasions  successfully  operated  under  such  conditions,  and  there  can 
be  no  question  that  when  the  diagnosis  is  sufficiently  distinct  such  a 
procedure  is  not  only  justifiable,  but  affords  the  best  hope  for  the 
patient. 

Abdominal  Preg-nancy. — In  the  second  of  the  two  classes  into  which, 
for  practical  convenience,  Me  have  divided  extra-uterine  gestation  the 


186  i'nj:<;yAycv. 

ovum  is  <l('Vol<)j)0(l  in  the  ;ilt(l(iiiiiii:il  ("ivilv.  It  is  as  vet  ;m  open  (jiics- 
tiou  wlictlu'i"  ill  sonic  casi's  tlic  j»rc'<i^^ii:mcy  is  primarily  aljdomiiial  (»r 
not.  l>anu's  hclicvi'S  that  it  |trol)al)ly  never  is  so,  on  aeeount  of  tlie 
ditliculty  of"  admitting  that  so  minnte  a  body  as  the  ovum  shouhl  bo  ahle 
to  fix  itself  on  the  smootli  peritoneal  surface.  He  therefore  thinks  that 
all  abdominal  })rc<:nancics  ai'c  primarily  cither  tul)al  <jr  ovarian,  the  sacr 
in  which  they  wviv  contained  having  given  way,  and  the  ovmn  having 
retained  its  vitality  through  partial  attachment  to  the  original  sac.  This 
theory  is  opjwsed  to  that  of  the  majority  of  writers,  and,  although  it  may 
})erhaps  render  the  facts  less  difficult  to  understand,  it  is  purely  hypo- 
thetical. There  is  no  evidence  to  show  that  in  nujst  cases  there  is  an 
early  laceration  of  a  tubal  or  t)varian  sac.  That  the  chorion  villi  do 
gralt  themselves  u})on  the  surrounding  j)eritoneum  is  certain,  and  is 
observed  in  all  cases  of  abdominal  gestation.  It  is  not  more  difficult  to 
imagiue  them  doing  this  from  their  very  first  development  than  a  little 
later ;  for  it  must  be  allowed  that  if  such  laceraticm  does  occur,  in  most 
cases  it  can  only  be  when  pregnancy  is  very  slightly  advanced.  \  On  the 
■whole,  therefore,  it  seems  not  unreasonable  to  admit  the  usual  exj)lana- 
tion  of  these  cases,  that  the  ovule,  already  im])rcgnated,  cscaj)ed  the 
gras])  of  the  Fallopian  tuljc  and  fell  info  the  aljdominal  cavity,  where 
it  I'ooted  itself  and  developed.!  Some  have,  indeed,  supposed  tliat 
abdominal  pregnancy  may  occasionally  arise  in  consequence  of  sj)ermato- 
zoa  finding  their  way  into  the  peritoneal  cavity  and  there  meeting  and 
impregnating  an  ovule  discharged  from  the  Graafian  follicle.  Such  an 
event  one  would  suppose  to  be  almost  impossible,  but  Koeberle's  case, 
already  quoted,  proves  that  it  has  actually  occurred.  The  probability 
is  that  it  is  by  no  means  rare  for  impregnated  ovules  to  drop  into  the 
peritoneal  cavity,  and  that  the  majority  of  those  that  do  so  perish  with- 
out doing  any  harm.  AV'hen  they  do  survive,  however,  the  chorion  villi 
sprout,  attach  themselves  to  the  sui'rounding  structures,  and  eventually 
develop  into  a  j)lacenta.  The  mode  in  which  the  chorion  villi  are 
attached  and  the  arrangement  of  the  maternal  bhjod-vessels  have  never 
yet  been  worked  out,  and  would  form  a  very  interesting  subject  for 
investigation.  The  precise  scat  of  attachment  varies,  and  the  ])lacenta 
has  been  found  fixed  to  most  of  the  alidominal  viscera,  either  those  con- 
tained in  the  ])elvis  proper,  or  it  may  be  the  intestines,  or  to  the  iliac 
fossa  ;  most  frequently,  apparently,  the  ovum  finds  its  way  into  the 
retro-uteri  ne  cul-de-sac. 

Formation  of  a  Cyst  round  the  Ovnni. — The  subsequent  changes 
vary  much.  In  the  large  majority  of  cases  the  ovum  produces  consider- 
able irritation,  resulting  in  the  exudation  of  jdastic  material,  which  is 
thrown  around  it  so  as  to  form  a  secondary  cyst  or  cai)sule,  in  which 
maternal  vessels  are  largelv  developed,  and  which  stretches,  jxiri  jH(yf<ii, 
with  the  growth  of  the  ovum  (Fig.  85).  The  density  and  strength  of 
this  cyst  are  found  to  be  very  different  in  diflerent  cases;  sometimes  it 
forms  a  complete  and  strong  covering  to  the  ovum,  at  others  it  is  very 
thin  and  only  })artially  developed,  but  it  is  rarely  entirely  absent.  As 
there  is  ample  space  for  the  development  of  the  ovum,  and  as  the  sec- 
ondarv  cvst  generally  stretches  and  grows  along  with  it,  most  cases  of 
abdominal  pregnancy  progress  without  any  very  i-cmarkable  symptoms, 


ABNORMAL  PREGNANCY. 


187 


beyond  occasional  severe  attacks  of  i)ain,  until  tiie  full  term  of  prej^- 
iiancy  lias  been  reached.  Sometimes,  however,  the  cyst  lacerates,  and 
there  is  an  escape  of  blood  into  the  alxlominal  cavity,  accompanied  In 
more  or  less  prostration  and  coUapse,  which  may  ])rove  fatal,  but  from 
which  the  patient  more  generally  rallies.     The  fcetus,  now  dead,  will 


Fig.  85. 


Uterus  and  Foetus  in  a  case  of  Abdominal  Pregnancy. 

remain  in  the  abdomen,  and  will  undergo  changes  and  produce  results 
similar  to  those  which  we  shall  presently  describe  as  occurring  in  cases 
progressing  to  the  full  period. 

In  most  cases,  at  the  natural  termination  of  pregnancy  a  strange  series 
of  phenomena  occurs :  pseudo-labor  comes  on,  there  are  more  or  less  fre- 
quent and  strong  uterine  contracfioiis,  possibly  an  esca])e  of  blood  from 
the  vagina,  the  discharge  of  the  broken-down  uterine  decidua,  and  even 
the  establishment  of  lactatiou.  Sometimes  the  contractions  of  the 
abdominal  muscles  produced  by  this  ineffective  labor  have  been  so  strong 
as  to  cause  the  laceration  of  the  adventitious  cyst  surrounding  the  foetus 
and  the  escape  of  blood  and  liquor  amnii  into  the  abdominal  cavity, 
with  a  rapidly  fatal  result.  INIore  frequently  laceration  does  not  occur, 
and  the  spurious  labor-pains  continue  at  intervals  until  the  foetus  dies, 
possibly  from  pressure,  but  more  often  from  effusion  of  blood  into  the 
tissue  of  the  placenta,  and  consequent  asphyxia.  Occasionally  the  foetus 
has  apparently  lived  a  considerable  time,  in  some  cases  even  for  several 
months,  after  the  natural  limit  of  pregnancy  has  been  reached. 

Changes  after  the  Death  of  the  Foetus. — It  is  after  the  death  of 
the  foetus  that  the  dangers  of  abdominal  pregnancy  generally  commence, 
and  they  are  numerous  and  various.  The  subsequent  changes  that 
occur  are  well  worthy  of  study.  (Occasionally  the  foetus  has  been 
retained  for  a  length  of  time,  even  until  the  end  of  a  long  life,  without 
producing  any  serious  discomfort,  and  in  many  cases  of  this  kind  several 
normal  pregnancies  and  deliveries  have  subsequently  tal^en  placcA  Even 
when    the  extra-uterine   gestation    appears    to    be  tolerated,    and    has 


ISS 


PREGXAyCY. 


Fig.  86. 


reinaiiiod  for  Ion*;  witlioiit  pi'oduciiiM;  any  luul  cfT'ccts,  sciinus  svmptoms 
may  be  siuldciily  developed  ;  so  that  no  woman  uiuler  siieli  eireiim- 
stanccs  can  be  considered  sale.  Tlie  conditioji  of  these  retained  fietuses 
varies  niueli.  Most  eommoidy  the  li(pior  amnii  is  absorbed,  the  i^oHv^ 
slirinks  and  dies,  all  its  soft  strnctnres  are  changed  into  i^d'!""'!'''*-'?  '"id 
the  bones  only  remain  unaltered.  Sometimes  tins  eiiani^e  oe(-iTrs  witli 
great  rapidity.  1  have  elsewhere  '  recorded  a  case  of  extra-uterine  fo?- 
tation  in  which  at  the  fidl  term  of  })re<j;naney  the  fcetus  was  alive,  and 
the  woman  died  in  less  than  a  year  afterward.  On  post-mortem  the 
fcetus  was  found  entirely  transformed  into  a  greasy  mass  of  adij)o- 
cere  studded  with  fcetal  bones,  in  wliich  not  a  trace  of  any  of  the 
soft  parts  could  be  detected.  On  the  other  liand,  the  fcetus  may 
remain  unchanged :  in  the  ^Iiiseum  of  the  Collc":e  of  Surffoons 
there  is  one  wJiich  was  retained  in  the  abdomen  lor  Hfty-two  years, 

and    which    was   found    to   be    as    fresh  . -^ 

and  i^^^Xtfii^cd  as  a"  newborn  chiTdT  In 
other  c-ases  the  sac  and  its  contentslftrophy 
and  shrink,  and  calcareous  matter  is  d^ 
posited  in  them,  so  that  the  whole  become^ 
converted  into  a  solid  mass  known  as^ 
Uthopccdion  (Fig.  86).  The  cases,  ]iow-< 
ever,  in  which  the  retention  of  the  fctiLS 
gives  rise  to  no  mischief  are  quite  excep- 
tional. Generally  the  foetus  putrefies,  and 
this  may  ""Cither  i  m  mediately  "cause  fatal 
peritonitis  or  septicaemia,  or,  as  more  com- 
monly happens,  secondary  inflammation 
and  suppuration  of  the  sac.  Under  the 
influence  of  the  latter  the  sac  opens  exter- 
nally, either  directly  at  some  point  of  the 
abdominal  Avails,  or  indirectly  through  the 
vagina,  the  bowels,  or  even  the  bladder. 
Through  the  aperture  or  apertures  thus 
formed  (for  there  are  often  several  fistulous 
openings)  pus  and  the  bones  and  other 
parts  of  the  broken-down  firtus  arc  discharged  ;  and  this  may  go  on  for 
months,  and  even  years,  until  at  last,  if  the  patient's  sti-cngth  does  not 
give  way,  rhe  whole  contents  of  the  cyst  are  expelled  and  n-covery  takes 
])lace.  From  various  statistical  observations  it  a])pcars  that  the  chances 
of  recovery  are  best  when  the  cyst  opens  througii  the  abdominal  walls, 
next  through  the  vagina  or  bladder,  and  that  the  foetus  is  discharged 
with  most  difficulty  and  danger  when  the  aperture  is  formed  into  the 
bowel.  At  the  best,  however,  the  process  is  long,  tedious,  and  full  of 
danger  ;  and  the  ])atient  too  often  sinks  during  the  attcm])t  at  expulsion, 
through  the  irritation  and  exhaustion  j)roduced  by  the  abundant  and 
long-continued  discharge. 

Diagnosis. — The  diagnosis  of  abdominal  gestation  is  by  no  means  so 
easy  as  might  be  thought,  and  the  most  experienced  practitionei*s  have 
been  mistaken  with  regard  to  it. 

^  Trans.  Obstet.  Soc.  London,  1865,  vol.  vii.  ))p.  1-6. 


(From  a  pivparatioii 


ill  t)if  Mubruin  of 


the  College  of  Surgeons.) 


ABNORMAL  PREGNANCY.  189 

The  most  chiirat'tcri.stic  symptom — altli()ii<;h  this  is  uot  so  common  as 
in  tubal  gestation — is  mctrorrhaoia  combined  with  the  general  signs  of 
pregnancy.  Very  severe  and  frequently  repeated  attacks  of  abd(jminal 
pain  are  rarely  absent,  and  should  at  once  cause  suspicio)],  especially  if 
associated  with  hemorrhage  and  the  discharge  of  a  decidual  membrane 
from  the  uterus.  They  are  supposed  by  some  to  depend  on  intercurrent 
attacks  of  peritonitis,  by  which  the  foetal  cyst  is  formed.  Parry  doubts 
this  explanation,  and  attributes  them  partly  to  the  distension  of  the  cyst 
by  the  growing  foetus  and  partly  to  pressure  on  the  surrounding  struc- 
tures. On  palpation  the  form  of  the  abdomen  will  be  observed  to  differ 
from  that  of  normal  pregnancy,  being  generally  more  developed  in  the 
transverse  direction,  and  the  rounded  outline  of  the  gravid  uterus  can- 
not be  detected.  #\Vhen  development  has  advanced  nearly  to  term  the  f. 
extreme  distinctness  with  which  the  foetal  limbs  can  be  felt  wdll  arouse  ^ 
suspicion. J  Per  ^;ftgfi'f^<:»i_the  os  and  cervix  jvill  be  felt  softened,  as  in 
ordinary  pregnancy,  but  often  displaced  by  the  pressure  of  the  cyst,  and 
sometimes  fixed  by  pe^imei^ridjc  jxihesionsj  either  of  these  signs  is  of 
great  diagnostic  value. 

By  bimanual  examination  it  may  be  possible  to  make  out  that  the 
utenis_^i_nQ,t  _greatly_enlai^ed,  and  that  it  is  distinctly  sep^ya^^  from 
tlie  bulk  of  the  tumor ;  these  facts,  if  recognized,  would  of  them- 
selves  disj)rove  tKe  existence  of  uterine  gestation.  The  diagnosis,  if 
the  foetal  limbs  or  heart-sounds  could  be  detected,  would  be  cleared 
ui)  in  any  case  by  the  uterine  sound,  which  would  show  that  the 
Uterus  was  empty  and  only  slightly  elongated.  But  we  must  be 
careful  not  to  resort  to  this  test  unless  the  existence  of  uterine  ges- 
tation is  positively  disproved  by  other  means.  As,  however,  it  places 
the  diagnosis  beyond  a  doubt,  it  should  always  be  employed  when- 
ever operative  procedure  is  in  contemplation.  Quite  recently  I  have 
seen  a  remarkable  case  w'hich  illustrates  the  importance  of  this  rule. 
The  case  had  been  diagnosed  as  abdominal  pregnancy  by  no  less  than 
six  experienced  practitioners,  and  was  actually  on  the  operating-table 
for  the  performance  of  laparotomy.  As  a  precaution,  having  some 
doubts  of  the  diagnosis,  I  suggested  the  passage  of  the  sound,  which 
entered  into  a  gravid  uterus,  the  case  proving  to  be  one  of  small  ovarian 
tumor  jammed  down  into  Douglas'  space  and  displacing  the  cervix  for- 
ward. Had  it  not  been  for  this  precaution  its  true  nature  would  certainly 
not  have  been  detected. 

Treatment. — The  treatment  of  abdominal  gestation  will  always  be  a 
subject  of  anxious  consideration,  and  there  is  much  difference  of  opinion 
as  to  the  proper  course  to  pursue.    |It  is  pretty  generally  admitted  thatt 
it  is  not  advisable  to  adopt  any  active  measures  until  the  full  term  of  I 
development  is  reached.     Puncturing  the  cyst  with  the  view  of  destroy-' 
ing  the  foetus  and  arresting  its  further  growth  has  been  practised,  but 
tiiere  are  good  grounds  for  rejecting  it,  for  there  is  not  the  same  immi- 
nent risk  of  death  from  rupture  of  the  cyst  as  in  tubal  foetatiou ;  and, 
even  if  tlie  destruction  of  the  foetus  could  be  brought  about,  there  would 
still  be  formidable  dangers  from  subsequent  attemjjts  at  elimination  or 
from  internal  hemorrhage. 

When  the  full  period   has  arrived,  the   child   being  still  alive,   as 


190  PREGNANCY. 

piovid  hy  auscultation,  nvc  have  to  consider  vlietliei*  it  may  not  lie 
advisable  to  j)eil"orni  gastrotoniy  before  the  lietus  i)erishes,  and  so  at 
least  save  the  life  of  the  i-hild.  Ihere  are  few  questions  of  greater  im- 
portance and  more  diflicult  to  settle.  The  tendency  of  medical  opinionA 
is  rather  in  i'avor  of  immediate  operation,  which  is  recommeii(lcd  i)y  I 
Velpcan,  Kiwisch,  Kocbcrle,  Schiocdcr,  Tait,  and  many  (jthcr  wi'itei-s, I 
whose  opinion  necessarily  carries  o;reat  wei<i:ht.  /'J'lie  ar<i;nments  used  iiy' 
favor  of  immediate  operation  are  that,  while  it  affords  a  probability  of 
saving  the  child,  the  risks  to  the  mother,  great  though  they  undoubtedly 
are,  are  not  greater  than  those  which  may  be  antici])ated  by  delaVj/  If 
we  put  off  interference,  the  cyst  may  i'U})turc  during  the  ineffectual 
efforts  at  labor,  and  death  at  once  ensue  ;  or  if  tiiis  docs  not  take 
place  other  risks,  Mhich  can  never  be  foreseen,  are  always  in  store  for  the 
patient.  She  may  sink  from  peritonitis  or  from  exhaustion  consequent 
on  the  eflforts  at  elimination  which  in  the  majority  of  cases  are  sooner  or 
later  set  up,  so  that,  as  Barnes  properly  says,  "the  patient's  life  may  l)e 
said  to  be  at  the  mercy  of  accidents  of  which  we  have  no  sufficient  Marn- 
ing."  i'On  the  other  hand,  if  we  delay,  Avhilc  we  sacrifice  all  hope  of 
saving^'the  chifd,  we  at  least  give  the  mother  the  chance  of  the  fcetation 
remaining  quiescent  for  a  length  of  time,  as  certainly  not  unfrequently 
occurs.  /  Thus,  Campbell  collected  62  cases  of  ultimate  recovery  after 
abdominal  gestation,  in  21  of  which  the  foetus  was  retained  without 
injury  for  a  numl)er  of  years.  Then  there  is  the  question  of  second- 
ary gastrotoniy,  which  consists  in  ()})erating  after  the  death  of  the 
foetus  when  urgent  symptoms  have  arisen — a  course  which  is  advo- 
cated by  Mr.  Hutchinson.  lu  favor  of  this  procedure  it  is  urged 
that  by  delay  the  inflammation  taking  place  about  the  cyst  will  have 
greatly  increased  the  chance  of  adhesions  having  formed  between  it 
and  the  abdominal  parietes,  so  as  to  shut  off  its  contents  from  the 
cavity  of  the  peritoneum.  The  more  effectually  this  has  been  accom- 
plished, the  greater  are  the  chances  of  recovery.  When  the  fietus  has 
been  dead  for  some  time  the  vascularity  of  the  cyst  will  also  be  less- 
ened, the  placental  circulation  will  have  ceased,  and  that  viscus  will 
have  become  solid  and  tough,  so  that  the  danger  of  hemorrhage  will 
be  much  diminished. 

It  will  be  seen,  therefore,  that  there  are  arguments  in  favor  of  each  of 
these  views.  The  results  of  the  primary  o])cration  are  far  less  favorable 
than  we  should  have,  a  prioi'i,  supposed.  Since  the  first  edition  of  this 
work  appeared  the  subject  has  been  carefully  studied  by  Dr.  Parry  in 
his  exhaustive  treatise  on  E.rira-\derme  Fivtatlon.  He  has  tlicre 
shown  that  Avhen  the  case  is  left  until  nature  has  shown  the 
channel  through  Avhicli  elimination  is  to  be  effected,  the  mortality  is 
17.35  per  cent,  less  than  in  the  cases  in  which  the  primary  operation 
was  performed.  His  conclusion  is  that  "  the  primary  operation  can- 
not be  too  forcibly  condemned.  It  is  not  too  much  to  say  that  this 
operation  adds  only  another  danger  to  a  life  already  trembling  in 
the  balance,  which  the  delusive  hope  of  Siiving  the  uncertain  life  of 
a  child  does  not  warrant  us  in  assuming."  It  is  only  just  to  remember, 
as  is  forcibly  ])ointed  out  by  Keller,  that  in  thcM'  days  of  advanced 
abdominal  surgery  a  better  result  might  be  anticipated  than  when  gas- 


ABNORMAL    PREGNANCY.  191 

trotoiny  was  pcrlbnned  in^  the  lKij)liazanl  way  whicli  was  usual  Ijofore 
we  had  gained  experience  Irom  ovariotomy.  No  doubt  minute  eare 
in  tlie  performance  of  the  operation,  a  due  attention  to  its  details — 
studiously  avoiding,  as  much  as  i)ossible,  the  passage  of  blood  and  the 
contents  of  the  cyst  into  the  peritoneal  cavity — and  a  fi'ee  use  of 
antise])ties  Avould  materially  lessen  its  peril.  This  conclusion  is 
well  illustrated  in  a  recent  interesting  paper  by  Thomas,  who  relates 
three  successful  cases  of  laparotomy  in  abdominal  pregnancy.' 

Mode  of  Performing-  the  Operation. — The  operation,  then,  sliould 
be  performed  with  all  the  precautions  with  which  we  surround  ovari- 
otomy. The  incision,  best  made  in  _the  Hnea  alba,  should  not  be  greater 
than  is  necessary  to  extract  the  foetus,  and  may  be  lengthened  as  occasion 
requires.  It  has  been  suggested  that  should  the  head  be  felt  presenting 
above  the  vagina,  the  intervening  structures  should  be  divided  and  the 
foetus  withdrawn  by  the  forceps.  This  procedure  was  actually  adopted 
with  success  in  1816  by  Dr.  John  King  of  Edisto  Island,  South  Caro- 
lina, llf  there  are  no  adhesions  the  walls  of  the  cyst  should  be  stitchedj 
to  the  margin  of  the  incision,  so  as  to  shut  it  off  as  completely  as  possi-l 
ble  from  the  peritoneal  cavity,  i  This  has  been  specially  insisted  on  byf 
Braxton  Hicks,  and  should  never  be  omitted.  The  special  risk  is  not 
so  much  the  wounding  of  the  peritoneum  as  the  subsequent  entrance  of 
septic  matter  from  the  cyst  into  its  cavity.  Another  cardinal  rule,  both 
in  primary  and  secondary  gastrotomy,  is  to  make  no  attempt  to  remove 
the  placenta.  Its  attachments  are  generally  so  dcep-seati*!  and  diffused 
that  any  endeavor  to  separate  it  is  likely  to  be  attended  with  profuse 
and  uncontrollable  hemorrhage,  or  with  serious  injury  to  the  structure 
to  which  it  is  attached.  Many  of  the  failures  af\er  operating  can  be 
traced  to  a  neglect  of  this  rule.  *The  best  subsequent  course  to  pursue,! 
after  removing  the  foetus  and  arresting  all  hemorrhage,  either  by  ligature  I 
or  the  actual  cautery,  is  to  sponge  out  the  cyst  as  gently  as  possible, 
sprinkle  the  cavity  with  iodoform  or  with  equal  parts  of^  tannin  and 
salicylic  acid,  as  recommended  by  Freund,^  and  then  to  bring  the  upper 
part  of  the  wound  into  apposition  Avith  sutures,  leaving  the  lower  open, 
with  the  cord  protruding,  so  as  to  ensure  an  outlet  for  the  escape  of  the 
placenta  as  it  slips  down.li  The  subsequent  treatment  must  be  specially 
directed  to  favor  the  escape  of  the  discharge  and  to  prevent  the  risk  of 
septicsemia.  These  objects  may  be  much  aided  by  injections  of  anti- 
septic fluids,  such  as  solution  of  carbolic  acid  or  diluted  Condy's  fluid ; 
and  it  would  probably  be  advisable  to  place  a  drainage-tube  in  the  lower 
angle  of  the  wound.  It  may  be  Avell  to  point  out  that  there  ig  no 
operation  in  which  a  scrupulous  following  of  the  antiseptic  method 
on  Sir  Joseph  Lister's  principles  is  so  likely  to  be  useful. 

As  long  as  the  placenta  is  retained  the  danger  is  necessarily  great, 
and  it  may  be  many  days,  or  even  weeks,  before  it  is  discharged. 
When  once  this  is  effected  the  sac  may  be  expected  to  contract,  and 
eventually  to  close  entirely. 

[In  cases  where  the  foetus  is  living  and  viable  it  is  essential  to  success  I 
that  both_cyst  and  placenta  shall  bejigated  and  exsected,  step  by  step,  I 

^  Am.  Journ.  of  Med.  ScL,  1879,  vol.  Ixxvii.  p.  17. 
^  Edin.  Med.  Journ.,  vol.  1883-84,  p.  521. 


s 


192  PREayAycr. 

until  the  whole  growth  is  removed  after  theejiild  shall  have  been  deliv- 
ered. To  leave  the  plaeenta,  as  in  eases  wlieretfie  lu-tiis  has  lx,'en  <lea<I  i'or 
some  weeks,  is  to  endanger  the  life  oi'the  woman  in  the  vast  majority  of 
OLses,  not  so  mueh  from  septie  poisoning  as  hemorrhage,  or  both  in  eombi- 
nation.  Until  the  exseetive  method  was  iutrodueed  by  Dr.  August  Martin 
of  Berlin,  in  July,  1881,  there  liad  only  1  woman  escaped  death  out  of 
20  operated  upon,  and  in  her  ease  there  was  no  cyst,  and  she  made  an 
exeeetiingly  narrow  escape.  Since  Dr.  Martin  jierformed  his  operation  it 
has  been  repeated  and  perfected  by  Prois.  Lazarewitch of  Russia, Breiskv 
of  Vienna,  Ea.stman  of  Indianaj)olis,  and  Olshausen  of  Berlin,  all  of  the 
women  recovering,  and  the  child  of  the  last  case  being  alive  and  well  at 
five  mouths.  Prof.  Eastman  believes  his  case  to  have  been  purely  tubal  at 
the  time  of  operation,  aud  he  was  able  to  form  a  pedicle  by  fii-st  damp- 
ing and  then  ligating  the  vascular  connections  of  the  cyst  and  placenta  ; 
after  which  he  severed  the  stump.  Prof.  Breiskv  tied  and  exsected, 
little  by  little,  the  whole  ectopic  growth  in  his  case,  the  placenta  being 
located  at  the  dome  of  the  cyst;  and  his  form  of  ojK'ratiou  is  the  one 
which  will  be  found  most  frequently  practicable,  ^o  attempt  must  be 
jmade  to  separate  the  parts  by  tearing  or  peeling,  but  ligation  alone  can 
Ibe  relied  upon  to  prevent  sudden  and,  it  may  be,  uncontrollable,  hem- 
Jorrhage.  This  mode  of  operation  gives  a  promise  of  double  success  in 
the  forni  of  cases  almost  universally  fatal  from  1813  to  1881. — P^d.] 

Treatment  after  Foetal  Death. — ^Mien  the  foetus  is  dead,  or  when 
we  have  determined  not  to  attempt  primary  gastrotomy,  it  is  advisidjle 
to  wait,  very  carefully  watching  the  patient,  until  either  the  gravity  of 
her  general  symptoms  or  some  positive  indication  of  the  channel  through 
which  nature  is  about  to  attempt  to  eliminate  the  foetus  shows  us  that 
the  time  for  action  has  arrived.  If  there  be  distinct  bulging  of  the 
cvst  in  the  vagina  or  in  the  retro-vaginal  cul-de-sac,  especially  if  au 
opening  tias  formed  there,  we  may  properly  content  ourselves  with  aid- 
ing the  passage  of  the  foetus  through  the  channel  thus  indicated,  and 
removing  the  parts  that  present  piecemeal  as  they  come  within  reach, 
cautiously  enlarging  the  aperture  if  necessary.  [This  will  be  generally 
found,  on  the  average,  at  about  ten  weeks  after  fcetal  death,  at  which 
time  placental  changes  have  rendered  the  utero-placental  vascular  con- 
nections far  less  varicose  in  character,  and  exfoliation  can  take  place 
with  only  a  trifle  of  blood-loss. — Ed.]  If  die  sac  have  opened  into 
the  intestines,  the  expulsion  of  the  foetus  through^  this  cTTannel  is  so 
tedious  and  difficult,  the  exhaustion  attending  it  so  likely  to  jirove 
fatal,  and  the  danger  from  decomposition  of  the  fetus  through  jwssage 
of  intestinal  gas  so  great,  that  it  would  probably  be  best  to  attempt  to 
remove  it  by  gastrotomy,  especially  if  it  is  only  recently  dead  and  the 
greater  portion  is  still  retained. 

If  an  oj^ening  forms  at  the  abdominal  parietes,  or  if  the  symptoms 
determine  us  to  resort  to  secondary  gastrotomy  before  this  occui-s,  the 
operation  must  l;e  performed  in  the  same  way  and  with  the  same  pre- 
cautions as  primary  gastrotomy.  Here,  as  before,  the  safety  of  the  opera- 
tion must  greatly  depend  on  the  amount  and  firmness  of  the  adhesions  ; 
for  if  the  cyst  be  not  com])letely  shut  off  from  the  ])eritoneal  cavity,  the 
risks  of  the  operation   will  be  little  less  than  those  of  primary  gas- 


ABNORMAL  PREGNANCY.  193 

trotomy.  It  would  oliviously  materially  intlucneo  our  decision  and 
prognosis  if  we  could  determine  this  j)oint  hef'ore  operating.  Unfortu- 
nately, it  is  imjjossible,  as  the  experience  of  ovariotomists  proves,  to 
ascertain  the  existence  of  adhesions  with  any  certainty.  If,  however, 
we  find  that  the  abdominal  parietes  do  not  move  freely  over  the  cyst, 
and  if  the  umbilicus  be  de[)ressed  and  immovable,  the  presum})tion  is 
that  considerable  adhesions  exist.  If  they  are  found  not  to  be  present, 
the  cyst-walls  should  be  stitched  to  the  margin  of  the  incision,  in  the 
manner  already  indicated,  before  the  contents  are  removed. 

If  the  foetus  has  been  long  dead  and  its  tissues  greatly  altered,  its 
removal  may  be  a  matter  of  difficulty.  In  the  case  under  my  own  care, 
already  alluded  to,  the  fcctal  structures  formed  a  sticky  mass  of  such  a 
nature  that  I  believe  it  would  have  been  impossible  to  empty  the  cyst 
had  an  operation  been  attem])ted.  This  Avould  be,  to  some  extent,  a 
further  argument  in  favor  of  the  primary  operation. 

Opening-  of  Cyst  by  Caustics. — The  importance  of  adhesions  has 
led  some  practitioners  to  recommend  the  opening  of  the  cyst  by  potassa 
fusa  or  some  other  caustic,  in  the  hope  that  it  would  set  up  adhesive 
inflammation  around  the  aperture  thus  formed.  Several  successful 
operations  by  this  method  are  recorded,  and  it  would  be  worth  trying 
should  the  extreme  mobility  of  the  cyst  lead  us  to  suspect  that  no  adhe- 
sions existed.  If  we  have  to  deal  with  a  case  in  which  fistulous  open- 
ings leading  to  the  cyst  have  already  formed,  it  may,  perhaps,  be 
advisable  to  dilate  the  apertures  already  existing,  rather  than  make  a 
fresh  incision  ;  but  in  determining  this  point  the  surgeon  will  naturallv 
be  guided  by  the  nature  of  the  case  and  the  character  and  direction  of 
the  fistulous  openings. 

General  Treatment. — It  is  almost  needless  to  say  anything  of  gen- 
eral treatment  in  these  trying  cases;  but  the  administration  of  opiates  to 
allay  the  sufferings  of  the  patient  and  the  endeavor  to  support  the 
severely-taxed  vital  energies  by  appropriate  food  and  medication  will 
form  an  important  part  of  the  management.  Freund  specially  insists 
on  the  necessity  of  a  careful  regulation  of  the  boM^els,  and  on  making 
milk  the  staple  article  of  diet,  as  points  of  value  in  the  management 
of  cases  prior  to  ojieration. 

Gestation  in  a  Bilobed  Uterus. — A  few  words  may  be  said  as  to 
gestation  in  the  rudimentary  horn  of  a  bilobed  uterus,  to  which  consid- 
erable attention  has  of  late  years  been  directed  by  the  writings  of  Kuss- 
maul  and  others.     It  appears  certain  that  many  cases  of  supposed  tubal 
gestation  are  really  to  be  referred  to  this  category.   (Although  such  cases  ; 
are  of  interest  pathologically,  they  scarcely  require  much  discussion  from 
a  practical  point  of  view,  inasmuch  as  their  history  is  pretty  nearlv  ' 
identical  with  that  of  tubal  pregnancy.  )  The  rudimentary  horn  is  dis-' 
tended  by  the  enlarging  ovum,  and  after  a  time,  when  further  distension 
is  impossible,  laceration  takes  ])lace.  C  As  a  matter  of  fact,  all  the  thir- 
teen cases  collected  by  Kussmaul  terminated  in  this  way,  and  even  on 
post-mortem  examination  it  is  often  extremely  difficult  to  distinouish 
them  from  tubal  pregnancies.     The  best  way  of  doing  so  is  ])rol)ably 
by  observing  the  relations  of  the  rotnid  ligaments  to  the  tumor,  for  if 
the  gestation  be  tubal  they  will  be  found  attached  to  the  uterus  on  tlie 

13 


194 


rREayAXCY. 


inner  or  uterine  side  of"  the  eyst  ;  wln'reiis  if  tlie  pre»rnancy  he  in  a 
nuhnientary  liorn  ot"  the  uterus  they  will  he  puslud  outward  and  he 
external  to  the  sieJ  In  the  latter  ea.se,  moreover,  the  sae  "will  he 
prohahly  found  to  eontain  a  true  deeidua, 'whieh  is  not  the  ca.se  in  tuhal 
pregnaney.  Tiie  only  point  in  whieh  they  differ  is  that  in  eornual  \n'L%- 
uauey  ruj)ture  may  he  delayed  to  a  .somewhat  later  ])eriod  than  in  tuhal, 
on  aeeount  of  the  "reater  disteusihility  of  the  supplfiiieutarv  horn. 

Missed  Labor.— f-Tlie  term  "  missed  hihor,^^  is  aj)plied  to  an  exceed- 
ingly rare  class  of  cases  in  Avhieh,  at  the  full  jieriod  of  })regnancy,  lahor 
has  either  not  come  on  at  all,  or,  having  commenced,  the  pains  have 
.suhse([ueutly  passed  off,  and  the  foetus  is  retained  in  utero  for  a  very 
considerable  length  of  time^  Under  such  circumstances  it  has  usually 
happened  that  the  membranes  have  ruptured  at  or  about  the  ]»roper 
term,  and  the  access  of  air  to  the  fa'tus  in  utcro  has  been  followed  by 

Fig.  87. 


Contents  of  the('y.'~t  in  Dr.  Oklham>  (.a.-c  .iiMi>-c(l  Labor. 


decomposition.  A  putrid  and  offensive  discharge  has  then  commenced, 
and  eventually  ])ortions  of  the  disintegrating  foetus  iiave  been  expelled 
per  rdf/inam.  This  discharge  may  go  on  until  the  entire  f(etus  is  grad- 
ually thrown  off,  or  more  frcfjuently  the  i)atient  dies  from  septic;emia 
or  other  secondary  result  of  the  presence  of  the  decomposing  mass  in 
utero.  Thus,  ]McClintoek  relates  one  ca.se'  in  m  Inch  .symptoms  of  labor 
came  on  in  a  woman  45  years  of  age  at  the  exjx'cted  period  of  delivery, 
but  pas.sed  off  without  the  ex])ulsion  of  the  fVetus.  For  a  period  of 
sixty-seven  weeks  a  highly  oilensive  discharge  came  away,  with  i^ome 
few  bones,  and  she  eventually  died  with  symptoms  of  pyemia.    He  also 

'  Dublin  Quart.  Jovrn.,  Feb.  and  May,  1S64. 


ABNORMAL  PREGNANCY.  195 

cites  another  case  in  wliicli  tlie  ]>atient  died  in  the  same  way  after  the 
fa'tns  had  been  retained  for  eleven  years. 

Sometimes,  when  the  foetus  has  been  retained  for  a  length  of  time,  a 
further  source  of  danger  has  been  added  by  ulceration  or  destruction 
of  the  uterine  walls,  probably  in  consequence  of  an  ineffectual  attempt  at 
its  elimination.  This  occurred  in  Dr.  Oldham's  case  (Fig.  87),  in 
which  the  contained  mass  is  said  to  have  nearly  worn  through  the  ante- 
rior wall  of  the  uterus;  and  also  i^i  one  reported  by  Sir  James  Simp- 
son,' in  which  a  patient  died  three  mouths  after  term,  the  fretus  having 
undergone  fatty  metamorphosis,  an  opening  the  size  of  half  a  crown 
having  formed  between  the  transverse  colon  and  the  uterine  cavity.  It 
is  also  stated  that  "  the  uterine  walls  were  as  thin  as  parchment." 
{in  some  few  cases,  however,  probably  when  the  entrance  of  air  has 
been  prevented,  the  fcetus  has  been  retained  for  a  length  of  time  W'ith- 
out  decomposing  and  without  giving  rise  to  any  troublesome  symptoms.l 
Such  a  case  is  reported  by  Dr.  Cheston,^  in  which  the  foetus  remained  irv 
uiero  for  fifty-two  years. 

The  causes  of  this  strange  occurrence  are  altogether  unknown.  Gen- 
erally the  foetus  seems  to  have  died  some  time  before  the  proper  terra  for 
labor,  and  this  may  have  influenced  the  character  of  the  pains.  It  is 
probably  also  most  apt  to  occur  in  women  of  feeble  and  inert  habit  of 
body,  possibly  where  there  was  some  obstacle  to  the  dilatation  of  the 
cervix  wdiich  the  pains  were  unable  to  overcome.  Barnes  suggests  ^  that 
some  presumed  examples  of  missed  labor  "  Nvere  really  cases  of  intersti- 
tial gestation  or  gestation  in  one  horn  of  a  two-horned  uterus ;"  and 
Macdonald  *  recently  recorded  a  very  interesting  case  in  which  he  per- 
formed laparotomy  for  what  he  believed  to  be  a  uterine  fibroid,  but 
which  turned  out  to  be  one  horn  of  a  bifurcated  uterus  containing  a  foetus 
which  had  been  retained  for  more  than  a  year.  He  believes  that  most, 
if  not  all,  cases  of  "  missed  labor  "  are  of  this  kind,  delivery  at  term 
proving  impossible  because  of  the  narrow  connection  between  the  irajn-eg- 
nated  horn  and  the  cervix. 

Miiller  of  J^ancy  has  attempted  to  prove,  by  a  critical  examination 
of  published  cases^  that  most  examples  of  so-called  "  missed  labor " 
Avere  in  reality  cases  of  extra-uterine  fcetation  in  which  an  ineffectual 
attempt  at  parturition  took  place,  the  foetus  being  subsequently 
retained. 

From  what  has  been  said,  it  will  be  seen  that  the  dangers  arising 
from  this  state  are  very  considerable,  and  when  once  the  full  term  has  j 
passed  beyond  doubt,  especially  if  the  presence  of  an  offensive  dis-  ' 
charge  shows  that  decomposition  of  the  foetus  has  commenced  iit  would  j 
be  pi'oper  practice  to  empty  the  uterus  as  soon  as  possible!    The  neces-|i 
sary  precaution^  however,  is  not  to  decide  too  quickly  thatf  the  term  has 
really  passed ;;  and  therefore  we  must  either  allow  sufficient   time  to  1 
elapse  to  make  it  quite  certain  that  the  case  really  falls  under  this  cate-    i 
gory  or  have  unequivocal  signs  of  the  death  of  the  foetus  and  injury  to 
the  mother's  health.     If  we  had  to  deal  with  the  case  before  any  exten- 
sive decomposition  of  the  foetus  had  occurred,  we  probably  should  find 

^  Edin.  Med.  Jouni.,  1865.  =  3rrd.-CJnr.  Trans.,  1814. 

■^  Diseases  of  Women,  p.  445.  *  Edin.  Med.  Journ.,  vol.  18S4-S5,  p.  873. 


196  PREGNANCY. 

little  (lin'u'iihy  in  its  iiiaiiagenu'iit,  i'ov  the  proper  course  then  wouhl  be 
to  dilate  the  cervix  with  fiuid  dilators,  and  remove  the  iitetus  by  turn- 
ing ;  or  before  doing  so  we  might  endeavor  to  excite  uterine  action  by 
j)ressure  and  ergot.  If  the  case  did  not  come  under  observation  until 
disintegration  of  the  foetus  had  begun,  it  would  be  more  ilillieult  to  deal 
with,  it'  the  lu'tus  had  become  so  nmch  broken  up  that  it  was  being 
discharged  in  j)ieces.  Dr.  McClintock  says  that  "  in  regard  to  treatment 
our  measures  should  consist  mainly  of  j)alliatives — viz.  rest  and  hip- 
baths— to  subdue  uterine  irritation  ;  vaginal  injections,  to  secure  clean- 
liness and  prevent  excoriation  ;  occasional  digital  examination,  so  its  to 
detect  any  fragments  of  bone  that  might  be  presenting  at  the  os,  and  to 
assist  in  removing  them,  'i'hese  are  plain  rational  measures,  and 
beyond  tliem  we  shall  scarcely,  perhaps,  be  justilied  in  venturing. 
Nevertheless,  under  certain  circumstances  1  would  not  hesitate  to  dilate 
the  cervical  canal  so  as  to  permit  of  examining  the  interior  of  the 
Avomb  and  of  extracting  any  fragments  of  bone  that  may  be  easily 
accessible;  but  unless  they  could  thus  be  easily  reached  and  removed, 
the  safer  course  woidd  be  to  defer,  for  the  present,  interfering  with 
them." ' 

n  It  may  be  doubted,  I  think,  whether,  considering  the  serious  results 
'  which  are  known  to  have  followed  so  many  cases,  it  would  not,  on  the 
whole,  be  safer  to  make  at  least  one  decided  effort,  under  chloroform,  to 
remove  as  much  as  possible  of  the  putrefying  uterine  contents  after  the 
OS  has  been  fully  dilated.  Such  a  procedure  would  be  less  irritating 
than  frequently-repeated  endeavors  to  pick  away  detached  portions  of 
the  fa?tus  as  they  present  at  the  os  uteri.  When  once  the  os  is  dilated, 
antiseptic  iutra-uterine  injections,  as  of  diluted  Condy's  fluid,  might 
safely  and  advantageously  be  used.  Unquestionably,  it  would  l)e  better 
])ractiee  to  interfere  and  empty  the  uterus  as  soon  as  we  are  (juite  satis- 
fied of  the  nature  of  the  case,  rather  than  to  delay  until  the  fwtus  has 
been  disintegrated.  Macdonald  thinks  that  abdominal  section  would 
be  the  best  course  to  pursue,  either  removing  the  sac  entire  or  resoi'ting 
to  Porro's  operation.  This  advice  is  based  on  the  assumption  that 
"  missed  labor  "  is  essentially  the  retention  of  a  foetus  in  one  horn  of  a 
biloljed  uterus — a  theory  which  certainly  cannot  yet  be  taken  as  proved. 
[Causes  of  "  Missed  Labor." — From  several  cases  that  have  been 
rej)orted  in  the  United  States  we  find  that  the  failure  of  the  uterus  to 
expel  its  contents  may  be  due  to  a  variety  of  causes.  If  we  are  certain 
that  the  foetus  is  actually  in  ntero,  that  there  is  no  pelvic  or  vaginal 
obstruction,  and  that  the  uterus  is  itself  of  normal  form,  then  we  must 
look  for  the  cause  of  difficulty  in  the  organ  itself.  By  an  examination 
of  our  reports  of  Ciesarean  operations  we  find  that  thei-e  iiave  been  sev- 
eral cases  in  which  the  power  of  the  uterine  contractions  was  insuffi- 
cient jtp. overcome  the  resistance  to  expansion  in  the  cervix.  This  niayj. 
be  due  either  to  a  want  of  contractile  force  in  the  muscular  coat,  toll 
a  change  in  the  tissues  of  the  cervix  as  the  result  of  inflammation,  or'' 
to  both  conditions  combined.  AVhere  the  muscular  power  of  the  uterus 
is  in  its  integrity,  the  resistance  in  the  cervix  may  Ije  such  that  the  os 
may  remain  unchanged  after  it  is  slightly  opened,  and  the  patient  con- 

^  Dublin  Quart.  Jouru.,  vol.  xxxvii.  p.  314. 


I 


ABNORMAL  PREGNANCY.  VM 

tiime  in  labor  until  the  contractile  power  of  the  uterus  is  exhausted 
wlieu  all  nuiscular  contraction  will  cease.  Efllbrts  at  exjiulsiyn  may 
recur  at  intervals  covering  a  period  of  many  months,  when  they  will 
cease  finally.  In  two  Csesareau  cases  in  the  tJnited  States,  the  subjects i 
being  blackf  there  was  found  a  calcareous  incrustation  over  and  around  I 
the  internal  os  uteri.  I  The  first  operation  ^vas  performed  in  Virginia 
in  1828  upon  a  multipara  of  25.^  She  was  taken  in  la])or  at  term,  and 
had  })ains  for  two  or  three  days  together,  at  intervals,  for  about  four 
weeks,  after  which  pains  returned  occasionally  during  fifteen  months. 
The  cervix  admitted  the  index  finger,  and  in  time  the  foetus  became 
putrid.  When  operated  upon  she  had  carried  the  fcetus  two  years. 
There  was  very  little  hemorrhage  in  the  operation,  although  the  uterus 
failed  to  contract,  and  for  this  reason  was  sutured.  The  woman  died 
in  the  second  week,  of  peritonitis,  following  an  attack  of  indigestion 
produced  by  a  meal  of  animal  food  and  cider.  The  second  case,  also  a 
multipara,  was  operated  upon  in  Georgia  in  1877,  after  a  labor  of  four 
days,  by  Dr.  Theodore  Starbuck,  who  describes  the  deposit  as  "  ossific." 
The  child  was  dead,  and  the  woman  died  of  internal  hemorrhage  very 
suddenly  on  the  third  day.^ 

In  a  third  case,  also  black,  the  cause  of  retention  appears  to  have 
been  a  prevention  of  the  descent  of  the  foetus,  from  its  arm  and  leg 
being  secured  within  the  uterus.  The  woman  was  33  years  old  and  the 
mother  of  one  child,  and  w^as  operated  upon  by  Dr.  J.  C  Egau  of 
Shreveport,  Louisiana,  August  25,  1860.^  On  May  4, 1857,  while  at 
work  in  the  field,  she  felt  a  sudden  and  violent  pain  in  the  left  side  ; 
fainted,  remained  insensible  so  long  as  to  be  thought  dead,  but  finally 
revived,  and  was  pronounced  four  months  pregnant.  Labor  began  in 
November  ;  the  os  dilated,  head  presented,  but  did  not  descend  ;  pains 
continued  at  intervals  for  a  month.  In  the  fall  of  1858  an  abscess 
opened,  leaving  a  fistula  1:^  inches  below  the  umbilicus.  When  ope- 
rated upon  nearly  two  years  later,  she  was  greatly  emaciated  and  affected 
with  hectic  fever.  The  uterus  being  adherent,  the  peritoneal  cavity  was 
not  opened.  When  the  foetus  was  extracted,  its  left  foot  and  hand  were 
wanting,  and,  search  being  made,  were  found  in  a  pouch  on  the  left  side 
of  the  uterus,  enclosed  by  bands  which  were  cut  for  their  liberation. 
The  uterus  was  examined  bimanually  to  make  sure  that  the  cervix  was 
sufficiently  open  for  drainage.  The  decomposed  foetus  had  been  carried 
thirty-three  months  after  maturity.  Dr.  Egan  believes  that  a  partial 
rupture  of  the  uterus  took  place  at  the  time  of  her  attack  in  the  field, 
and  that  the  arm  and  leg  were  caught  in  its  partial  cicatrization.  The 
woman  made  a  good  recovery. 

jNIuch  light  is  thrown  upon  a  possible  way  of  accounting  for  some  of 
the  mysterious  cases  of  missed  labor,  which  have  been  claimed  to  be 
extra-uterine  in  order  to  account  for  them,  by  a  case  recently  operated 
upon  in  Portland,  Maine,  by  Dr.  Stanley  P.  Warren,  and  kindly 
reported  to  me  by  letter.     The  woman  was  a  native,  of  Scotch-Irish 

[^  Am.  Journ.  Med.  ScL,  vol.  xviii.  p.  257.] 
[^  Communicated  by  the  operator,  1S80.] 

l/^N.  0.  Med.  and  iiurg.  Journ.,  July,  1877,  p.  35;  also  communicated  bv  operator, 
1878.] 


198  riii:ayAycY. 

(lesot'Ut,  :i<fc'(l  32,  and  niotlior  of  :\  cliild  of  13,  Slio  la.st  nicnstruated  in 
JamiaiT,  1884.  Siipjxist'd  accidental  al)()rtion  in  May,  as  tlici-c  was 
hemorrhage;  tlic  j)hysician  said  he  had  removed  the  phicenta,  and  there 
was  a  tliick  "  molasses-like  "  dischart;i'  alterward.  Dr.  ^^'arren  was 
called  in  a  week  later ;  f'onnd  metro-peritonitis  and  a  tumor  of  about 
four  inches  in  diameter  in  the  riii;ht  <z;roin.  The  peritonitis  hecame  trcn- 
eral,  and  Dr.  ^^^  was  in  attendance  for  fil'teen  days.  On  duly  1st  the 
tumor  was  in  the  median  line,  and  fu-tal  movements  and  heart-sounds 
distinct.  Labor  expected  about  October  28 ;  subsequent  j^estation 
normal.  Was  called  October  20lh,  at  11  p.  m.  ;  found  no  true  pains; 
pain  apparently  abdominal,  rather  than  uterine,  and  continuous  in  the 
back  and  over  the  sides  of  the  uterus.  Foetus  transverse,  with  head  to 
right;  pulse  152.  Xo  change  for  several  days.  Second  week  in 
November  foiuid  child  dead.  Xext  four  weeks  slight  occasional  chills, 
and  temperature  102°  for  two  or  three  nights,  but  usually  normal. 
Absolutely  no  expulsive  pains.  Cervix  reached  with  difficulty,  and 
finger  passed  through  a  long  tubular  neck,  but  foetus  not  reached.  Cer- 
vix absolutely  closed  from  December  21st  to  29th;  pulse  120,  temjK-ra- 
ture  100°  to'l02°.  Attempted  to  dilate  with  s])onge  tent,  but  could 
not  pass  it  into  the  uterine  cavity.  December  30th  attempted  to  ojten 
cervix  by  digital  dilatation,  and  succeeded  finally  in  passing  a  cranio- 
clast,  but  the  parts  closed  as  soon  as  the  dilators  were  removed.  Patient 
in  a  profound  shock.  After  stimulating  for  an  hour,  performed  Ca^sa- 
rean  section  ;  hemorrhage  slight ;  peritoneum  adherent  everywhere  to 
uterus;  uterine  wall  I  inch  thick;  child  ]>resented  by  right  arm  and 
side ;  placenta  thin  and  far  advanced  in  fatty  degeneration  ;  no  hem- 
orrhage on  its  removal;  uterus  did  not  contract;  sutured  by  continuous 
stitch  with  catgut.  Child  8J  pounds.  Woman  rallied  slightly,  Init 
died  of  shock  in  28  hours.  Drs.  T.  A.  Foster  and  S.  C.  Gordon  were 
associated  with  Dr.  Warren  in  the  management  of  the  case. 

It  would  a]^])ear  in  this  instance  of  mjssed  labor  that  the  changes 
produced  b\-( metro-peritonitis  prevented  the  natural  dilatation  of  the 
cervixi  and  the  contractile  action  of  the  muscular  coat  of  the  uterus. 
Possibly,  fatty  degeneration  of  the  muscular  fibres  had  taken  place,  but 
this  could  not  be  ascertained,  as  there  Avas  no  autopsy. 

The  Cesarean  case  of  Dr.  Brodie  S.  Herndon  of  Fredericksburg, 
Virginia,  operated  upon  with  success  in  1845,  bears  a  close  resemblance 
in  many  of  its  features  to  that  of  Dr.  Warren.  The  subject  was  a 
white  multipara  of  30,  whose  ])ains  of  labor  gave  place  to  the  contin- 
uous pain  and  other  characteristic  symptoms  of  peritonitis.  This  disease 
lasted  a  mouth,  during  which  time  the  fluid  contents  of  the  uterus 
escaped  and  the  vaginal  discharge  became  very  ofllensive.  Five  weeks 
after  the  jieritonitis  commenced  the  os  uteri  admitted  two  fingers,  and 
attempts  at  dilatation  were  made,  l)ut  failed.  Under  ergot  an  otlensive 
placenta  was  expelled,  but  the  fcetus  could  not  be  removed.  The 
Avoman  being  greatly  wasted  and  her  room  filled  with  stench,  the  Cfesa- 
rcan  operation  was  performed  on  November  16,  forty-six  days  after  the 
first  signs  of  labor  appeared.  The  uterus  being  adherent,  the  perito- 
neal cavity  was  Jiot  exposed  ;  the  uterus  was  sponged  out,  but  did  not 
contract ;  it  was  closed  in  the  suturing  of  the  abdomen.     The  patient 


DISEASES  OF  PREGXAXCY.  199 

made  a  good  recovery.  As  m  tlie  Warren  ease,  the  uterus  became 
unsuited  for  performing  the  functions  of  hibor  by  reason  of  changes  in 
its  tissues  eti'ected    by  inflammatory  action. — Ed.] 


CHAPTER  yil. 
DISEASES  OF  PREGNANCY. 

The  diseases  of  pregnancy  form  a  subject  so  extensive  that  they 
niight  well  of  themselves  furnish  ample  material  for  a  separate  treatise. 
The  pregnant  woman  is  of  course  liable  to  the  same  diseases  as  the  non- 
pregnant ;  but  it  is  only  necessary  to  allude  to  those  whose  course  and 
eifects  are  essentially  modified  by  the  existence  of  pregnancy  or  which 
have  some  peculiar  effect  on  the  patient  in  consequence  of  her  condi- 
tion. There  are,  moreover,  many  disorders  which  can  be  distinctly 
traced  to  the  existence  of  pregnancy.  Some  of  them  are  the  direct 
results  of  the  sympathetic  irritations  which  are  then  so  commonly 
observed,  and  of  these  several  are  only  exaggerations  of  irritations 
w'hich  may  be  said  to  be  normal  accompaniments  of  gestation.  These 
functional  derangements  may  be  classed  under  the  head  of  neuroses, 
and  they  are  sometimes  so  slight  as  merely  to  cause  temporary  inconve- 
nience, at  others  so  grave  as  seriously  to  imperil  the  life  of  the  patient. 
Another  class  of  disorders  is  to  be  traced  to  local  causes  in  connection 
with  the  gravid  uterus,  and  are  either  the  mechanical  results  of  pres- 
sure or  of  some  displacement  or  morbid  state  of  the  uterus  ;  while  the 
origin  of  others  may  be  said  to  be  complex,  being  partly  due  to  sympa- 
thetic irritation,  partly  to  pressure,  and  partly  to  obscure  nutritive 
changes  produced  by  the  pregnant  state. 

Derang-ements  of  the  Digestive  System. — Among  the  sympathetic 
derangements  there  are  none  which  are  more  common,  and  none  which 
more  frequently  produce  distress,  and  even  danger,  than  those  Avhich 
affect  the  digestive  system.  Under  the  heading  of  "  The  Signs  of 
Pregnancy  "  the  frequent  occurrence  of  nausea  and  vomiting  has  already 
been  discussed  and  its  most  probable  causes  cousi'cTered  (p.  147).  A 
certain  amount  of  nausea  is  indeed  so  common  an  accompaniment  of 
pregnancy  that  its  consideration  as  one  of  the  normal  symptoms  of  that 
state  is  fully  justified.  We  need  here  only  discuss  those  cases  in  which 
the  nausea  is  excessive  and  long  continued,  and  leads  to  serious  results 
from  inanition  and  from  the  constant  distress  it  occasions.  Fortunately, 
a  pregnant  woman  may  bear  a  surprising  amount  of  nausea  and  sick- 
ness without  constitutional  injury,  so  that  apparently  almost  all  aliments 
may  be  rejected  without  the  nutrition  of  the  body  very  materially  suf- 
fering. At  times  the  vomiting  is  limited  to  the  earlv^jjaTt_jj£,t'i^l'\^'' 
when  all  food  is  rejected,  and  when  there  is  a  Ircquent  retching  of 


200  PRIiayA.WCY. 

glairy,  transparent  fluid,  in  scvoi-al  cases  mixed  with  bile,  while  at  the 
latter  ))art  of  the  day  the  stomach  jnay  be  able  to  retain  a  suflicient 
(juantity  ol"  food  and  the  nausi-a  disaj)|)ears.  ^  Jn  other  cases  the  nausea 
:uid  vomitin<5  are  aliuust  incessant}  i'he  j)atieut  leels  constantly  .sick, 
^^'j  and  the  mere  taste  or  sight  of  f'ootl  may  bring  on  excessive  and  painful 
>  vomiting.  The  duration  of  this  distressing  accojujianiment  of  j)reg- 
iiancy  is  also  variable,  ((ienerally  it  connnences  between  the  second  anj.1 
third  months,  and  disa])])ears  after  the  woman  luus  quickened^  Some- 
times, however,  it  begins  with  conception,  and  continues  inial)ated  initil 
the  ])regnancy  is  over. 

Symptoms  of  the  Graver  Cases. — In  the  worst  class  of  ca.«cs, 
when  all  nourishment  is  rejected  and  when  the  retching  is  continu- 
ous  and  painful,  sym])toms  of  very  great  gravity,  which  may  even 
prove  fatal,  develop  themselves.  The  countenance  Ijccomes  haggard 
from  suffering,  the  tongue  dry  and  coated,  the  epigastriiun  tender  on 
pressure,  and  a  state  of  extreme  nervous  irritability,  attended  with  rest- 
lessness and  lo.ss  of  sleep,  becomes  establTsIied.  In  a  still  more  aggra- 
vated degree  there  is  general  feverishness,  with  a  rapid,  small,  and 
thready  pulse.  Extreme  emaciation  supervenes,  the  result  of  wast- 
ing from  lack  of  nourishment.  The  breath  is  inten.sely  feticl_and 
the  tongue  dry  and  black.  The  vomited  matters  are  sometimes 
mixed  with  blood.  The  patient  becomes  profoundly  exhausted,  a 
low  form  of  delirium  ensues,  and  death  may  follow  if  relief  is  not 
obtained.  , 

Prognosis.— \Symptoms  of  such  gravity  are  fortunately  of  extreme 
.   rarity,  but  they  do  from  time  to  time  arise  and  cause  much  anxiety> 
j    Gueuiot  collected  118  cases  of  this  form  of  the  disease,  out  of  which 
'    46  died;   and,  out  of  the   72  that  recovered,   in    42   the   symptoms 
only  ceased   when    abortion,   either    spontaneous    or    artificially   pro- 
duced, had  occurred.     When   pregnancy  is  over  the  symptoms  occa- 
sionally cease  with  marvellous  rapidity.     The  power  of  retaining  and 
as.similating  food  is  rapidly  regained  and  all  the  threatening  symptoms 
disap]iear. 

Treatment. — In  the  milder  forms  of  obstinate  vomiting  one  of  the 
first  indications  will  be  to  remedy  any  morbid  state  of  the  })rimse  via?. 
The  bowels  will  not  unfrequently  be  found  to  be  obstinately  consti- 
])ated,  the  tongue  loaded,  and  the  breath  offensive;  and  when  attention 
has  been  ]>aid  to  the  general  .state  of  the  digestive  organs  by  general 
a])erient  medicines  and  antacid  remedies,  such  as  bismuth  and  .^xla 
and  lif^uor  pepticus  after  meals,  the  tendency  to  vomiting  may  abate 
witliout  furtlier  treatment. 

The  careful  regulation  of  the  diet  is  very  important.  Great  benefit | 
is  often  derived  from  recommending  the  patient  not  to  rise  from  the! 
recinnbent  ))osition  in  the  morning  until  she  has  taken  something. 
Half  a  cup  of  milk  and  lime-water,  or  a  cuji  of  strong  coffee,  or  a 
little  rum  and  milk  or  cocoa  and  milk,  a  glass  of  sparkling  kou- 
mis.s,  or  even  a  morsel  of  biscuit,  taken  on  waking,  often  has  a 
remarkable  cti'ect  in  diminishing  the  nausea.  AVhen  any  attempt  at 
swallowing  .solid  food  brings  on  vomiting,  it  is  better  to  give  u]>  all 
])retenee  at  keeping  to  regular  meals,  and  to  order  .such  light  and  easily 


DfSEASES   OF  PREGNAXCV.  201 

assiinilatod  food  at  short  intervals  as  can  he  retained.  Iced  milk,  ^^•ith 
lime  or  soda-water,  given  frequently,  and  not  more  than  a  mouthful  at 
a  time,  will  frequently  be  retained  when  nothing  else  will.  Cold  beef- 
jelly,  a  spoonful  at  a  time,  will  also  be  often  kept  down.  iSparkling 
koumiss  has  been  strongly  recommended  as  very  useful  in  such  cases, 
and  is  worthy  of  trial.  It  is  well,  however,  to  bear  in  mind,  in  regu- 
lating tiie  diet,  that  the  stomach  is  fanciful  and  capricious,  and  that  the 
patient  may  be  able  to  retain  strange  and  apparently  unlikely  articles  of 
food,  and  that  if  she  expresses  a  desire  for  such  the  experiment  of  letting 
her  have  them  should  certainly  be  tried. 

The  medicines  that  have  been  recommended  are  innumerable,  and  the 
practitioner  will  often  have  to  try  one  after  the  other  unsuccessfully,  or 
may  tind,  in  an  individual  case,  that  a  remedy  will  prove  valuable  which 
in  anotiier  may  be  altogether  powerless.  Amongst  those  most  generally 
useful  are  effervescing  draug^lits,  containing  from  three  to  five  minims 
of  dilute  hydrocyanic  acid  ;  the  creasote  mixture  of  the  Pharmacopoeia ; 
tmcture  of  nux  vomica,  in  doses  of  five  or  ten  minims;  single  minim 
doses  of  viuum.  ipecacuanhre,  every  hour  in  severe  cases,  three  or  four 
times  dailyTfTffexse  wiiicllare  less  urgent ;  salicine,  in  doses  of  three  to 
five  grains  three  times  a  day,  recommended  by  Tyler  Smith  ;  oxalate  of 
cerium  in  the  form  of  a  pill,  of  which  three  to  five  grains  may  be  given 
tliree  times  a  day — a  remedy  strongly  advocated  by  Sir  James  Simpson, 
and  Avhich  occasionally  is  of  undoubted  service,  but  more  often  fails ; 
the  compound  pyroxylic  spirit  of  the  London  Pharmacopoeia,  in  doses 
of  five  minims  every  four  hours,  with  a  little  compound  tincture  of 
cardamoms — a  drug  which  is  comparatively  little  known,  but  which 
occasionally  has  a  very  marked  and  beneficial  effect  in  checking  vomit- 
ing ;  opiates  in  various  forms — which  sometimes  prove  useful,  more 
often  not — may  be  administered  either  by  the  mouth,  in  pills  contain- 
ing from  lialf  a  grain  to  a  grain  of  opium,  or  in  small  doses  of  the 
solution  of  the  bimeconate  of  morphia  or  of  Battley's  sedative  solu- 
tion, or  subcutaneously — a  mode  of  administration  which  is  much  more 
often  successful.  The  hydrochlorate  of  ^CQcalue  is  said  to  be  very 
efficacious :  two  grains  are  dissolved  in  five  ounces  of  water  by  means 
of  spirit,  of  which  mixture  a  teaspoonful  may  be  taken  every  hour. 
Antipyrine  in  ten-grain  doses  has  sometimes  proved  useful.  If  there 
is  much  tenderness  about  the  epigastrium,  one  or  two  leeches  may  be 
advantageously  applied,  or  one-third  of  a  grain  of  morphia  may  Jje 
sprinkled  on  the  surface  of  a  small  blister,  or  cloths  saturated  in  laudanum 
may  be  kept  over  the  pit  of  the  stomach.  The  admrnisfration  j>fr 
rectum  of  twenty  grains  of  chloral,  combined  with  the  same  amount 
of  bromide  of  potassium,  in  a  small  enema,  is  said  to  very  useful.  In 
many  cases  I  have  found  that  the  application  of  a  spinal  ice-bag  to  the 
cervical  vertebrre,  in  the  manner  recommended  by  Dr.  Chapman,  has 
checked  the  vomiting  when  all  drugs  have  failed.  The  ice  may  be 
placed  in  one  of  Chapman's  spinal  ice-bags,  and  applied  for  half  an 
hour  or  an  hour  twice  or  three  times  a  day.  It  invariablv  produces  a 
comforting  sensation  of  warmth,  which  is  always  agreeable  to  the 
patient.  Ice  may  be  given  to  suck  ad  libitum,  and  is  very  useful; 
while  if  there  be  much  exhaustion  small  quantities  of  iced  cham- 


202  rrj'JGXAycY. 

j):ii;ii(.'    may   also    he    t^iyeii    Intin    time   to   time.     The  aj)j)Hr.itioii  of 
the  ether  spray  over  the  ej)igastrium  has  been  highly  recommended. 

lua^jinueh  as  the  vomiting;  unqnestionably  has  its  origin  in  the  uterus, 
it  is  only  natural  that  practitioners  should  endeavor  to  check  it  by  reme- 
dies calculated  to  relieve  the  irritability  of"  that  organ.  Tiius,  morphia 
in  the  form  of  pessaries  jjcr  rtnjiiiain  or  belladonna  aj)plied  to  the  cervix 
has  been  reconunendcd,  and  the  former  especially  is  often  of  undoubted 
service.  A  pessary  containing  one-third  to  half  a  grain  of  morj)liia* 
may  be  introduced  night  and  morning  uitliout  interfering  with  other 
methods  of  treatment.  Dr.  Henry  Beunet  directs  especial  attention  to 
the  cervix,  Mhich,  he  says,  is  almost  ahvays  congested  and  inflamed  and 
covered  with  granular  erosions.  This  condition  he  reconunends  to  be 
treated  by  the  application  of  nitrate  of  silver  through  the  speculum. 
Dr.  Clay  of  ^Manchester  corroborates  this  view,  and  strongly  advocates, 
especially  when  vomiting  continues  in  the  latter  mouths,  that  one  or  two 
leeches  should  be  applied  to  the  cervix.  Excejition  may  fairly  be  taken 
to  both  these  methods  of  treatment  as  being  somewhat  hazardous,  unless 
other  means  have  been  tried  and  failed.  I  have  little  doubt,  however, 
that  in  many  cases  a  state  of  uterine  congestion  is  an  important  factor 
in  keeping  up  the  unduly  irritable  condition  of  the  uterine  fibres,  and 
an  endeavor  sliould  always  be  made  to  lessen  it  by  insisting  on  absolute 
rest  in  the  recumbent  posture.  Of  the  importance  of  this  precaution 
in  obstinate  cases  there  can  be  no  question.  Dr.  Copeman  of  Xorwich 
strongly  recommended  dilatatiijn_of  the  cervix  by  the  finger,  and  stated 
that  lie  found  it  very  scrvicealile  in  checking  nausea.  It  is  obvious  that 
this  treatment  must  be  adopted  with  great  caution,  as,  roughly  ])erformcd, 
it  might  lead  to  the  production  of  abortion.  Dr.  Hewitt's  views  as  to 
the  dependence  of  sickness  on  flexions  of  the  uterus  have  already  been 
adverted  to,  and  reasons  have  been  given  for  doubting  the  general  cor- 
rectness of  his  theory.  It  is  quite  likely,  however,  that  well-marked 
dis])lacements  of  the  uterus,  either  forward  or  backward,  may  serve 
to  intensify  the  irritability  of  the  organ.  Cazeaux  mentions  an  obsti- 
nate case  immediately  cured  by  replacing  a  retroverted  uterus.  A  care- 
ful vaginal  examination  should  therefore  be  instituted  in  all  intractable 
cases,  and  if  distinct  displacement  be  detected  an  endeavor  should  be  made 
to  support  the  uterus  in  its  normal  axis.  If  retroverted,  a  Hodge's 
jK'Ssary  may  be  safely  employed;  if  anteverted,  a  small  air-ball  pessary, 
as  recommended  by  Hewitt,  should  be  inserted.  I  believe,  however, 
that  such  displacements  are  the  exception,  rather  than  the  rule,  in  cases 
of  severe  sickness. 

The  importance  of  promoting^  nutrition  l)y  every  means  in  our  ])ower 
should  always  be  borne  in  mind.  The  effervescing  koumiss,  which  can 
now  be  readily  ol)tained,  I  have  found  of  great  value,  as  it  can  often  be 
retained  when  all  other  aliment  is  rejected.  The  exhaustion  produced 
by  want  of  food  soon  increases  the  irritable  state  of  the  nervous  sys- 
tem, and  if  the  stomach  will  not  retain  anything  Me  can  only  combat 
it  by  occasional  mitrient  encmata  of  strong  beef-tea,  yolk  of  cixi:,  and 
the  "like. 

The  Production  of  Artificial  Abortion. — Finally,  in  the  worst 
class  of  cases,  when  all  treatment  has  faileil,  and  when  the  patient  has 


DISEASES  OF  FEEGNANCY.  203 

fallen  into  the  eonditioh  of  extreme  ])i'ostration  already  deserihetl,  M-e 
may  be  driven  to  consider  the  necessity  of  ])rodaciii<r  abortion.  For- 
tunately, cases  jnsti fy in <i^  this  extreme  resource  are  of  <^reat  rarity,  but 
nevertheless  there  is  abundant  evidence  that  every  now  and  then  women 
do  die  from  uncontrollable  vomiting  whose  lives  might  have  been  saved 
had  the  pregnancy  been  brought  to  an  end.  The  value  of  artificial 
abortion  has  been  abundantly  proved.  Indeed,  it  is  remarkable  how 
ra})idly  the  serious  symptoms  disappear  when  the  uterus  is  emptied  and 
the  tojision  of  the  uterine  fibres  lessened.  It  has  fortunately  Init  rarely 
fallen  to  my  lot  to  have  to  perform  this  operation  for  intractable  vomit- 
ing. In  one  such  case  the  patient  was  reduced  to  a  state  of  the  utmost 
prostration,  having  kept  hardly  any  food  on  her  stomach  for  many 
weeks,  and  when  I  first  saw  her  she  was  lying  in  a  state  of  low  mutter- 
ing delirium.  Within  a  few  hours  after  abortion  was  induced  all  the 
threatening  symptoms  had  disappeared,  the  vomiting  had  entirely  ceased, 
and  she  was  next  day  able  to  retain  and  absorb  all  that  was  given  to  her. 
The  value  of  the  operation,  therefore,  I  believe  to  be  undoubted. 
Where  it  has  failed  it  seems  to  have  been  on  account  of  undue  delay. 
Owing  to  the  natural  repugnance  which  all  must  feel  toward  this  plan, 
it  has  generally  been  postponed  until  the  patient  has  been  too  exhausted 
to  rally.  If,  therefore,  it  is  done  at  all,  it  should  be  before  prostration 
has  advanced  so  far  as  to  render  the  operation  useless.  In  these  cases 
the  obvious  indication  is  to  lessen  the  tension  of  the  uterus  at  once,  aud 
therefore  the  membranes  should  be  punctured  by  the  uterine  sound,  so 
as  to  let  thu  liquor  amnii  drain  away;  and  this  may  of  itself  be  suffi- 
cient to  accomplish  the  desired  effect.  It  is  almost  needless  to  add  that! 
no  one  would  be  justified  in  resorting  to  this  expedient  without  having! 
his  opinion  fortified  by  consultation  with  a  fellow-practitioner.  I 

Other  disorders  of  the  digestive  system  may  give  rise  to  con- 
siderable discomfort,  but  not  to  the  serious  peril  attending  obstinate 
vomiting.  Amongst  them  are  loss  of  appetite,  acidity  and  heartburn, 
flatulent  distension,  aud  sometimes  a  capricious  appetite,  M'hich  assumes 
the  form  of  longing  for  strange  and  even  disgusting  articles  of  diet. 
Associated  with  these  conditions  there  is  generallv  derano-ement  of  the 
whole  intestinal  tract,  indicated  by  furred  tongue  and  sluggish  bowels, 
aud  they  are  best  treated  by  remedies  calculated  to  restore  a  healthy 
condition  of  the  digestive  organs,  such  as  a  light,  easily-digested  diet, 
mineral  acids,  ve^etalile  bitters,  occasional  aperients,  bismuth  and  soda, 
and  pepsine.  The  indications  for  treatment  are  not  differenf  from  those 
whicli  accompany  the  same  symptoms  in  the  non-pregnant  state. 

Diarrhoea  is  an  occasional  accompaniment  of  pregnancy,  often  depend- 
ing on  errors  of  diet.  When  excessive  and  continuous  it  has  a  decided 
tendency  to  induce  uterine  contractions,  and  I  have  frequently  observed 
premature  labor  to  follow  a  sharp  attack  of  diarrhrca.  It  should,  tliere- 
fore,  not  be  neglected,  and  if  at  all  excessive  should  be  checked  by  the 
usual  means,  such  as  chalk  mixture  with  aromatic  confection  and  small 
doses  of  laudanum  or  chlorodyne.  The  possibility  of  apparent  diar- 
rhoea being  associated  with  actual  constipation,  the  fluid  matter  finding- 
its  way  past  the  solid  materials  blocking  up  the  intestines,  should  be 
borne  in  mind. 


204  PREGXAXCY. 

(jtiistii^atioii  is  imioli  nmrc  coiimnni,  and  is  indeed  a  very  ^rencral 
accoinpauimc'iit  uf  ])re<|:i)an( y,  even  in  N\«inien  \\\\o  do  not  sufl'er  from 
it  at  otlicr  times.  It  partly  dejiends  on  the  meelianieal  interference  of 
tlie  trravid  uterus  Avitli  the  ])roj)er  movements  of  tlie  intestines,  and 
j)art]y  on  deftvtive  innervation  of  the  howels  resulting  from  the  altered 
state  of  the  1)Io(m1.  The  tii-st  indication  will  be  to  remetly  this  defi-et 
by  appropriate  diet,  sueh  as  fnsh  i'ruits,  bro\yn_bread,  oatme-al  ]>orridge, 
etc.  Some  medicinal  treatment  will  also  be  necessary,  and  in  selecting 
the  drugs  to  be  used  eare  should  be  taken  to  choose  such  as  are  mild 
and  unirritatiug  in  their  action  and  tend  to  improve  the  tone  6i'  the 
nuiscular  coat  of  the  intestine.  A^small  quantity  of  aperient  mineral 
■\vater  in  the  early  morning,  such  as  tlie  Ilnnyadi,  Friedrich^halle,  or 
l^ullna  water,  often  answei*s  very  well ;  or  an  occ-asional  dose  of  the  con- 
fection of  sulphur;  or  a  pill  containing  three  or  four  grains  of  the 
extract  of  colocynth,  whh  a  quarter  of  a  grain  of  the  extract  of  nux 
vomicn  and  iT grain  of  extract  of  hvoscvamus  at  bedtime;  or  a  tea- 
spoonful  of  the  compound  liquorice  powder  in  juilk  at  bedtime.  Con- 
stipation is  also  sometimes  effectually  cond)ated  Ijy  administering,  twice 
daily,  a  pill  containing  a  couple  of  grains  of  insjiissated  ox-gall,  with 
a  quarter  of  a  grain  of  extract  of  belladonna.  Knemata  of  soa))  and 
water  are  often  ver}-  useful,  and  have  the  advantage  of  uot  disturb- 
ing  the  digestion.  In  the  latter  mouths  of  pregnancy,  especially  in  the 
few  weeks  preceding  delivery,  the  irritation  produced  by  the  collection 
of  hardened  feces  in  the  bowel  is  a  not  infrequent  cause  of  the  annoy- 
ing false  pains  which  then  so  commonly  trouble  the  patient.  In  order 
to  relieve  them  it  will  be  necessary  to  empty  the  bowels  thoroughly  by 
an  aperient/ such  as  a  good  dose  of  castor  oil,  to  which  fifteen  or  twenty 
minims  of  laudanum  may  be  advantageously  added.)  Should  the  rec- 
tum become  loaded  with  scybalous  masses,  it  may  be  necessary  to  break 
down  and  remove  them  by  mechanical  means,  provided  we  are  unable 
to  effect  this  by  co]")ious  enemata. 

Hemorrhoids. — The  loaded  state  of  the  rectum  so  common  in  preg- 
nancy, combined  with  the  mechanical  effect  of  the  pressure  of  the  gravid 
uterus  on  the  hemorrhoidal  veins,  often  ])roduces  very  troublesome 
symptoms  from  piles.  '  In  such  cases  a  regular  and  gentle  evacuation 
of  the  bowels  siiould  be  secured  daily,  so  as  to  lessen  as  much  as  ]>os- 
sible  the  congestion  of  the  veins. y  Any  of  the  aperients  already  men- 
tioned, especially  the  sulphur  electuary,  may  be  used.  Dr.  Fordyce 
Barker  '  insists  that,  contrary'  to  the  usual  imi)re.ssion,  one  of  the  best 
remedies  for  this  purpose  is  a  pill  containing  a  grain  or  a  grain  and  a 
lialf  of  powdered  aloes,  Avith  a  quarter  of  a  grain  of  extract  of  nux 
vomica,  and  that  castor  oil  is  distinctly  iirejudicial  and  apt  to  increase 
the  symptoms.     I  have  certainlv  found  it  answer  well  in  several  cases. 

IAVf.en  the  piles  are  tender  and  swollen  they  should  be  freely  covered  with 
an  ointment  consisting  of  four  grains  of  muriate  of  morphia  to  an 
ounce  of  simple  ointment,  or  with  the  ung.  galla?  c.  opio  of  the  Phar- 
'  macopoeia  ;  and,  if  ])rotruded,  an  attempt  should  be  made  to  push  them 
gently  above  the  sphincter,  l)y  which  they  are  often  unduly  constricted. 
Relief  may  also  be  obtained  by  frequent  hot  fomentations,  and  some- 
'  Ttte  Puerperal  Diseases,  p.  33. 


DISEASES  OF  PREGNANCY.  205 

times,  when  the  piles  are  niueh  swollen,  it  will  be  found  useful  to 
puncture  tlieni,  so  as  to  lessen  the  congestion,  before  any  attempt  at 
reduction  is  made. 

Ptyalism. — ^V  profuse  discharge  from  the  salivary-  glands  is  an  occa- 
sional  distressing  accompaniment  of  pregiiaiicy!  It  is  generally  cou- 
fined  to  the  eai:ly  niontlis,  but  it  occasionally  continues  during  the  whole 
period  of  gestation,  and  resists  all  treatment,  only  ceasing  when  delivery 
is  over.  Under  such  circumstances  the  discharge  of  saliva  is  sometimes 
enormous,  amounting  to  several  quarts  a  da}',  and  the  distress  and 
annoyance  to  the  patient  are  very  great.  In  one  case  under  my  care  the 
saliva  poured  from  the  mouth  all  day  long,  and  for  several  months  the 
patient  sat  with  a  basin  constantly  by  her  side,  incessantly  emptying 
her  mouth,  until  she  was  reduced  to  a  condition  giving  rise  to  really 
serious  anxiety.  This  profuse  salivation  is  no  doubt  a  purely  nervous 
disorder,  and  not  readily  controlled  by  remedies.  Astringent  gargles 
containing  tannin  and  chlorate  of  potash,  frequent  sucking  of  ice  or  of 
tannin  lozenges,  inhalation  of  turpentine  and  creasote,  counter-irritation 
over  the  salivary  glands  by  lilisters  or  iodine,  the  continuous  galvanic 
current  applied  over  the  parotids,  the  bromides,  opiuni  internally,  small 
dos^_of^^elladonna  or  atropine,  may  all  be  tried  in  turn,  but  none  of 
them  can  be  depended  on  with  any  degree  of  confidence. 

Toothache  and  Caries  of  the  Teeth. — Severe  dental  neuralgia  is 
also  a  frequent  accompaniment  of  pregnancy,  especially  in  the  early 
months.  When  purely  neuralgic,  quinine  in  tolerably  large  doses  is 
the  best  remedy  at  our  disposal ;  but  not  unfrequently  it  depends  on 
actual  caries  of  the  teeth,  and  attention  should  always  be  paid  to  the 
condition  of  the  teeth  when  facial  neuralgia  exists.  There  is  no 
doubt  that  pregnancy  predisposes  to  caries,  and  the  observation  of  this 
fact  has  given  rise  to  the  old  proverb,  ''  For  every  child  a  tooth."  jNIr. 
Oakley  Coles,  in  an  interesting  paper  ^  on  the  condition  of  the  mouth 
and  teeth  during  pregnancy,  refers  the  prevalence  of  caries  to  the  coex- 
istence of  acid  dyspepsia,  causing  acidity  of  the  oral  secretions.  There 
is  much  unreasonable  dread  amongst  practitioners  as  to  interfering  with 
the  teeth  dui'ing  pregnancy,  and  some  recommend  that  all  operations, 
even  stopping,  should  be  postponed  until  after  delivery.  It  seems  to 
me  certain  that  the  suffering  of  severe  toothache  is  likely  to  give  rise  to 
far  more  severe  irritation  than  the  operation  required  for  its  relief,  and 
I  have  frequently  seen  badly-decayed  teeth  extracted  during  pregnancy"N 
and  with  only  a  beneficial  result.  / 

Affections  of  the  Respiratory  Organs. — Amongst  the  derange- 
ments of  the  respiratory  organs,  one  of  the  most  common  is  gpas- 
modic  cough,  which  is  often  excessively  troublesome.  Like  many 
other  of  the  sympathetic  derangements  accompanying  gestati<iu, 
it  is  purely  nervous  in  character,  and  is  unaccompanied  by  ele- 
vatcd_  temperature,  quickened  pulse,  or  any  distinct  auscultatory 
phenomena.  In  character  it  is  not  unlike  whooping  cough.  The 
treatment  must  obviously  be  guided  by  the  character  of  the  cough. 
E_xpectorants  are  n9t  likelv  to  be  of  service,  while  benefit  may  be 
derived  from  some  of  the  autispasmpdic  class  of  drugs,  such  as  bel- 

'  Trans,  of  the  Odontoloc/kul  Society. 


tllO  \ 

cut/ 

rm/ 


206  rn  EC  NANCY. 

laddima,  liydrocyanie  acid,  o])iate.Sj|  or  hromide  of  jiotassiuni.  Such 
iviuc'dies  may  be  tried  in  .siuressiuii,  hut  will  oftou  be  fV)und  to  l)e 
ot"  little  value  in  arresting  the  cDUgli.  [Treatment  of  the  cough  of 
pregnancy  is  in  some  instances  of  great  im[)ortance  to  the  wifety  of  the 
icetus.  The  late  Dr.  S.  L.  Hollingsworth  of  Philadelphia  iufornietl 
the  writer  that  a  lady  came  under  his  care  who  liad  given  birth  to  two 
dead  ftctuses  at  separate  periods  while  under  that  of  a  well-known 
I'emale  physician  in  large  practice,  who  made  light  of  her  coughing 
attacks  as  simply  the  result  of  her  ])reguant  conditi(»n.  Dr.  H.  by  ap- 
jnopriate  treatment  checked  the  violence  of  her  attacks,  and  the  third 
child  was  born  alive. — Ed.]  Dyspnoea  may  nl'^n  bejiervous  in  cha- 
racter, and  sometimes  symptoms  not  unlike  iliu-c  df  spa.smodic  asthma 
are  produced.  Like  the  other  symj)athetic  disorders,  it,  as  well  as 
nervous  cough,  is  most  frequently  ol)served  during  the  early  months. 
(There  is  another  form  of  dyspnwa,  not  uncommonly  met  with,  M'hich 
is  the  mec^hanical^  result  of  the  interference  with  the  action  of  the 
dia])hragnT  aud~Tungs  by  the  pressure  of  the  enlarged  uterus.  Hence 
this  is  most  generally  troul>lesome  in  the  latter  months,  and  con- 
tinues unrelieved  until  delivery  or  until  the  sinking  of  the  uterine 
tumor  Avliich  immediately  precedes  it.  Beyond  taking  care  that  the 
l^ressure  is  not  increased  by  tight  lacing  or  injudicious  arrangeme 
of  the  clothes,  there  is  little  that  can  be  done  to  relieve  this  fo 
of  breath  lessuess. 

[Unless  the  patient  has  some  cardiac  lesion  she  Avill  find  nmch 
relief  from  insomnia  at  night  b}'  sleeping  on  her  back  in  a  reclined 
position.  An  inclined  ])]ane  may  be  improvised  by  using  a  four-foot 
board  about  eighteen  inches  wide,  avcH  packed  with  pillows,  and  ex- 
tending from  above  the  middle  of  the  bed  to  the  head-board  at  an 
angle  of  forty-five  degrees  or  less.  The  abdomen  of  the  patient  should 
be  anointed  twice  a  day  with  Avarm  olive  oil  or  inodorous  lanolin,  and 
she  should  bend  her  knees  in  bed  over  a  large  pillow,  to  relax  her 
abdomen  and  to  prevent  her  sli])ping  down  in  the  bed:  she,  in  fact, 
sits  on  the  })illow.  Her  head  should  also  be  supported  forward  on  a 
cruss-p  i  1  ]  ow. — Ed.  ] 

(Palpitation,  like  dyspnoea,  may  be  due  either  to  sympathetic  dis- 
turbance or  to  mechanical  interference  with  the  jtroper  action  of  the 
heart.'  When  occurring  in  weakly  women  it  may  be  relerred  to  the 
functional  derangements  which  accompany  the  chlorotic  conditi(»n  of 
the  blood  often  associated  with  pregnancy,  and  is  then  best  remedied  by 
a  general  tonic  regimen  and  the  administration  of  ferruginous  prei>:ii:a- 
tjons.  At  other  times  antispasmodic  remedies  may  be  indicated,  and  it 
is  .seldom  sufficiently  serious  to  call  for  much  special  treatment. 

Attacks  of  fainting-  are  not  rare,  especially  in  delicate  women  of 
liighly-developed  nervous  temperament,  and  are,  ])erhai>s,  most  common 
at  or  about  the  period  of  quickening.  In  most  ciises  these  attacks  can- 
not be  classed  as  cardiac,  but  are  more  probably  nervous  in  character, 
and  they  are  rarely  associated  with  complete  abolition  of  consciousness. 
They  rather,  therefore,  resendjle  the  condition  described  by  the  older 
authors  as  /ifpot/ieinia.  The  ])atient  lies  in  a  s(>mi-unconscions  condition 
with  a  ieeble  pulse  and  widely  dilated  l)upil,  and  this  state  lasts  for 


DISEASES  OF  FREG NANCY.  207 

varying  periods  from  a  few  minutes  to  half  an  liour  or  more.  In  one 
very  troublesome  case  under  my  care  the  condition  often  i-ecurred  as 
frequently  as  three  or  four  times  a  day,  I  have  observed  tliat  it 
rarely  occurs  when  the  more  common  sympathetic  ])henomena  of  preg- 
nancy, especially  vomiting,  are  present.  Sometimes  it  terminates  with 
the  ordinary  symptoms  of  hysteria,  snch  as  sobbing.  (The  treatment 
should  consist  during  the  attack  in  the  administration  of  diffusible 
stinudants,  such  as  ether,  sal-volatile,  and  valerian,  the  patient  being 
placed  in  the  recumbent  })osition,  with  the  head  low.i  If  frequently  re- 
})eatod  it  is  unadvisable  to  attempt  to  rally  the  patient  by  the  too  free 
administration  of  stimulants,  [in  the  intervals  a  generally  tonic  regi- 
men and  the  administration  of  ferruginous  remedies  are  indicated.  If 
they  recur  with  great  frequency  the  daily  application  of  the  spinal  ice- 
bag  has  proved  of  much  service,    l 

Extreme  Anaemia  and.  Chlorosis. — In  connection  with  disorders 
of  the  circulatory  system  may  be  noticed  those  which  depend  on  the 
state  of  the  blood.  The  altered  condition  of  the  blood,  which  has 
already  been  described  as  a  physiological  accompaniment  of  pregnancy 
(p.  143),  is  sometimes  carried  to  an  extent  which  may  fairly  be  called 
morbid  ;  and  either  on  account  of  the  deficiency  of  blood-corpuscles  or 
from  the  increase  in  its  watery  constituents  a  state  of  extreme  anaemia 
and  chlorosis  may  be  developed.  This  may  sometimes  be  carried  to  a 
very  serious  extent,  the  condition  amounting  to  that  known  as  "  perni- 
cious anaemia."  Thus,  Gusserow^  records  five  cases  in  which  nothing 
but  excessive  anaemia  could  be  detected,  all  of  which  ended  fatally. 
Generally,  when  such  symptoms  have  been  carried  to  an  extreme  ex- 
tent, the  patient  has  been  in  a  state  of  chlorosis  before  pregnancy.  In 
cases  of  this  aggravated  type  the  patient  will  probably  miscarry,  and 
the  induction  of  premature  labor  or  abortion  may  even  become  im2:)era- 
tive. 

[The  writer  once  made  an  interesting  autopsy  in  a  case  of  pernicious 
anaemia  that  went  to  full  term  and  was  delivered  by  an  accoucheur 
whose  patients  had  escaped  death  from  the  effects  of  labor  in  private 
practice  during  the  thirty  years  prior  to  this  event.  He  had  remarked 
some  weeks  before,  when  her  appearance  was  commented  upon  by  the 
writer,  "that  such  women  were  not  fit  to  have  children."  Death  took 
place  in  three  hours  after  the  birth  of  a  female  child  now  grown  up, 
and  was  evidently  due  to  an  amount  of  blood-loss  which  would  not  be 
felt  by  a  healthy  woman.  There  was  no  external  escape  of  blood 
after  the  uterus  contracted,  and  the  coagulae  in  the  uterus  and  vagina 
only  amounted  to  a  few  ounces.  She  was  the  most  anaemic  woman 
prior  to  her  lying-in  that  the  Avriter  has  ever  seen  in  a  pregnant 
state.— Ed.] 

Treatment. — The  treatment  must  of  course  be  calculated  to  improve 
the  general  nutrition  and  enrich  the  impoverished  blood  :  a  light  and 
easily  assimilated  diet,  milk,  eggs,  beef-tea,  and  animal  food — if  it  can 
be  taken — attention  to  the  proper  action  of  the  bowels^  a  due  amount 
of  stimulants,  and  abundance  of  fresh  air,  will  be  the  chief  indications 
in  the  general  management  of  the  case.     Medicinally,  ferruginous  prep- 

^Arch.f.  G>/n,  1871,  Bd.  ii.  S.  218. 


208  riiKoxANcr. 

aratioMs  will  bo  roquii'cd.  Sonic  j)i'af'titioiici"s  (thjcct,  apparciitlv  without 
sulliciL'iit  n-ason,  to  tlu'  admiiii-ti-alioi)  of  inni  diii-iii^  jn-cjiiiaiicv,  as 
liabk'  to  j)roinote  abortion.  This  uiil()un(k'(l  jn-cjiidicc  njay  pnjbaljly 
be  traced  to  the  .sii])posed  enunenat>;o<i;iie  jiroperties  oi'  the  pre})aration.s 
of  iron;  but  it"  the  general  condition  oi"  the  j)atient  indicate  sucji  medi- 
cation they  may  be  administered  without  any  fear.  I'rejiai-ations  of 
phos]>horus,  such  as  the  phosj)hide  ol"  /inc  or  free  ])hnsphorus,  also 
promise  favorably  and  are  well  worthy  of  trial.  / 

Some  of  tlie  more  a>;gravated  cases  are  associated  withja  considirablei 
amount  of  serous  efl"usiou  into  the  cellular  tissue,  generally  limited  to 
the  lower  extremities,  but  occasionally  extending  to  the  arms,  face,  and 
neck,  and  even  producing  ascites  and  })leuritic  ef!"usion.  1  Under  the 
latter  circumstances  this  complication  is,  of  course,  of  great  gravity, 
and  it  is  said  that  after  delivery  the  disa])pearance  ol"  the  serous  effu- 
sion may  be  accompanied  by  metastasis  of  a  fatal  character  to  the  lung.s 
or  the  nervous  centres.  This  form  of  oedema  must  be  distinguished 
from  the  slight  cedematous  swelling  of  the  feet  and  legs  so  commonly 
observed  as  a  mechanical  result  of  the  pressiu'e  of  the  gravid  uterus, 
and  also  from  those  cases  of  redema  associated  with  albuminuria.  The\ 
treatment  must  be  directed  to  the  cause,  while  the  disappearance  of  the 
effusion  niay  be  promoted  by  the  administration  of  diiu-etic  drinks,  the 
occasional  use  of  saline  aperients,  and  rest  jnjjie  horijzontjdj20si.tion. 

Albuminuria.— (-The  existence  of  albumen  in  the  urine  of  })rcgnant 
"women  has  for  many  years  attracted  the  attention  of  obstetricians,  and  it 
is  now  well  known  to  be  associated,  in  ways  still  imperfectly  understood, 
W'ith  many  important  puerperal  diseases.!  Its  ])resence  in  most  cases  of 
puerperal  eclampsia  was  long  ago  pointed  out  by  Lever  in  this  country 
and  Rayer  in  France,  and  its  association  with  this  disease  gave  rise  to 
the  theory  of  the  dependence  of  the  convulsion  on  uramiia,  which  is 
generally  still  entertained.  It  has  been  shown  of  late  years,  especially 
by  Braxton  Hicks,  that  this  association  is  by  no  means  so  universal  as 
was  supposed  ;  or,  rather,  that  in  some  cases  the  albuminuria  l"ollows 
and  does  not  precede  the  convulsions,  of  which  it  might  therelbre  be 
supposed  to  be  the  consequence  rather  than  the  cause;  so  that  further 
investigations  as  to  these  particular  points  are  still  required.  Modern 
researches  have  shown  that  there  is  an  intimate  connection  between 
many  other  affections  and  albuminuria  ;  as,  for  example,  certain  i"orms 
of  })aralysis,  either  of  special  nerves,  as  puerperal  amaurosis,  or  of  the 
S])inal  system  ;  cephalalgia  and  dizziness;  puerperal  mania;  and  pos- 
sibly hemorrhage.  It  cannot,  therefore,  be  doubted  that  albuminuria 
in  the  pregnant  woman  is  liable,  at  any  rate,  to  be  associated  with  grave 
disease,  although  the  present  state  of  our  knowledge  does  not  enable  us 
to  define  very  distinctly  its  ])recise  mode  of  action. 

The  presence  of  albumen  in  the  urine  of  ])regnant  women  is  far  from 
a  rare  phenomenon.  Blot  and  I^itzman  met  with  albuminuria  in  20 
per  cent,  of  pregnant  women  ;  which  is,  however,  far  above  the  esti- 
mate of  other  authors;  Fordyce  Barker'  thinks  it  occurs  in  about  1 
out  of  25  cases,  or  4  per  cent.;  while  Hofmeier-  found  it  in  137  out  of 

'  Amrrican  Jounxil  of  ObKtetric.t,  1878,  vol.  xi.  p.  449. 
*  Berlin,  klin.  Wocli.',  h?e[)t.,  1878. 


I 


DISEASES  OF  PREGNANCY.  209 

5000  deliveries  in  the  Berlin  Gyniceologicul  Institution,  or  2.74  per 
cent.  As  in  the  large  majority  of  these  cases  it  ra[)i(lly  (lisap})ears  alter 
delivery,  it  is  obvious  that  its  presence  must,  in  a  large  proportion  of 
cases,  depend  on  temporary  causes,  and  has  not  always  the  same  serious 
imj)ortance  as  in  the  non-pregnant  state.  This  is  further  proved  by  the 
undoubted  fact  that  albumen,  rapidly  disa])])earing  after  delivery,  is 
often  found  in  urine  of  pregnant  women  who  go  to  term  and  jiass 
through  labor  without  any  unfavorable  sym])toms. 

Pressure  by  the  Gravid  Uterus. -|^The  ol)vious  facts  that  in  preg- 
nancy the  vessels  supplying  the  kidneys  are  subjected  to  mechanical 
pressure  from  the  gravid  uterus,  and  that  congestion  of  the  venous  cir-  ^ 
culatiou  of  those  viscera  must  necessarily  exist  to  a  greater  or  less  degree, 
suggest  that  here  wq  may  find  an  explanation  of  the  frequent  occurrence 
of  albuminuria.)  This  view  is  further  strengthened  by  the  fact  that  the 
albumen  rarely  appears  until  after  the  fifth  month,  and  therefore  not  !  ^k> 
until  the  uterus  has  attained  a  considerable  size ;  and  also  that  it  is  com-  ■ 
paratively  more  frequently  Jnet  with  in  primiparse,  in  whom  the  resist- 
ance of  the  abdominal  parietes,  and  consequent  pressure,  must  be  greater 
than  in  women  who  have  already  borne  children.  It  is  indeed  probable 
that  pressure  and  consequent  venous  congestion  of  the  kidneys  have  an 
important  influence  in  its  production  ;  but  there  must  be,  as  a  rule,  some 
other  factors  in  operation,  since  an  equal  or  even  greater  amount  of 
pressure  is  often  exerted  by  ovarian  and  fibroid  tumors  without  any 
such  consequences.  They  are  probably  complex.  (One  important  con- 
dition is  doubtless  the  increased  amount  of  work  the  kidneys  have  to  do 
in  excreting  the  waste  procfucts^oT'tlienfoeTus^as  well  as  those  of  the 
mother.  /The  increased  arterial  tension  throughout  the  body  associated 
with  hypertrophy  of  the  heart,  known  to  exist  in  pregnancy,  also 
operates  in  the  same  direction.  Bat  in  the  large  majority  of  cases, 
although  these  conditions  are  present,  no  albuminuria  exists,  and  they 
must  therefore  be  looked  upon  as  predisposing  causes,  to  which  some 
other  is  added  before  the  albumen  escapes  from  the  vessels.  AVhat  this 
is  generally  escapes  our  observation,  but  probably  any  condition  pro- 
ducing sudden  hypertemia  of  the  kidneys  and  giving  rise  to  a  state 
analogous  to  the  first  stage  of  Bright's  disease — such,  for  example,  as 
sudden  exposure  to  cold  and  impeded  cutaneous  action — may  be  suf- 
ficient to  set  a  light  to  the  match  already  prepared  by  the  existence  of 
pregnancy.  It  has  more  recently  been  pointed  out  that  a  transient  albu- 
minuria, disappearing  in  a  few  days,  is  very  common  after  delivery,  and 
probably  depends  on  a  catarrhal  condition  of  the  urinary  tract.  Inger- 
sten  observed  this  in  50  out  of  153  deliveries,  and  in  15  only  had  any 
albumen  existed  before  the  confinement.'  In  addition  to  these  tem- 
jjorary  causes  it  must  not  be  forgotten  that  pregnancy  may  supervene 
in  a  ]>atient  already  suiFering  from  Bright's  disease,  when  of  course 
the  albumen  will  exist  in  the  urine  from  the  commencement  of 
gestation.  * 

The  various  diseases  associated  with  the  presence  of  albumen  in  the 
urine  will  require  separate  consideration.  Some  of  these,  especially 
puerperal  eclampsia,  are  amongst  the  most  dangerous  complications  of 

1  Zeilschrift  f.  OebttrL,  1879,  Band  v.  Heft  2. 
14 


210  rni:axAycr. 

prognancv.  Others,  such  as  paraly-is,  ccplialalgia,  dizzinoss,  may  also 
be  of  (•()nsi(leral)le  gravity.  'Jlie  jux-cisc  mode  of  their  produetioii,  and 
whether  they  can  be  traced,  as  is  generally  believed,  to  the  retention  of 
urinary  elements  in  the  i)lood,  either  nrea(jr  free  carbonate  of  ammonia 
prodni-ed  by  its  decomposition,  or  whether  the  two  are  only  common 
results  of  some  undetermined  cause,  will  be  considered  when  we  ((tme 
to  discuss  j)uerperal  convulsions.  Whatever  view  may  ultimatelv  l>e 
taken  on  these  jjoints,  it  is  sufficiently  obvious  that  albuminuria  in  a 
pregnant  woman  must  constantly  be  a  source  of  nuuh  anxiety,  and  must 
induce  us  to  look  forward  Mith  considerable  apprehension  to  the  termi- 
nation of  the  case. 

Prognosis. — We  are  scarcely  in  possession  of  a  sufficiently  large 
number  of  oljservations  to  justify  any  very  accurate  conclusions  as  to  the 
risk  attending  albuminuria  during  pregnancy,  but  it  is  certainly  by  no 
means  slight.  Hofraeier  believes  that  albuminuria  is  a  most  severe 
complication  both  for  woman  and  child,  even  when  uncomplicated  with 
eclampsia.  The  prognosis,  he  thinks,  depends  on  whether  it  is  acute  in 
its  onset — that  is,  coming  on  within  a  few  days  of  labor — or  is  extended 
over  several  weeks.  The  former  is  more  likely  to  pass  entirely  away 
after  delivery,  M'hile  in  the  latter  there  is  more  risk  of  the  morbid  state 
of  the  kidneys  becoming  permanent  and  leading  to  the  establishment  of 
Bright's  disease  after  the  pregnancy  is  over.  Goubeyre  estimated  that 
49  per  cent,  of  primiparse  who  have  albuminuria,  and  who  escape 
eclampsia,  die  from  morbid  conditions  traceal)]e  to  the  albuminuria. 
This  conclusion  is  prol)al)ly  much  exaggerated,  l)Ut  if  it  even  ai)})rox- 
imate  to  the  truth  tlie  danger  must  be  verv  great. 

Besides  the  ultimate  risk  to  the  mother,  albuminuria  strongly  ])redis- 
poses  to  abortion,  no  doubt  on  account  of  the  imperfect  nutrition  of  the 
foetus  by  blood  impoverished  by  the  drain  of  albuminous  materials 
through  the  kidneys.  This  fact  has  been  observed  by  luany  writers. 
A  good  illustration  of  it  is  given  by  Tanner,'  who  states  that  4  out  of  7 
women  he  attended  suffering  from  Bright's  disease  during  |)regnaucy 
aborted,  one  of  them  three  times  in  succession. 

Symptoms. — The  symptoms  accompanying  albuminuria  in  preg- 
nancy are  by  no  means  uniform  or  constantly  ])resent.  That  which 
most  frequently  causes  suspicion  is  the  anasarca — not  only  the  redcma- 
tous  swelling  of  the  lower  limbs  which  is  so  conuuon  a  consequence  of 
the  pressure  of  the  gravid  uterus,  but  also  of  the  face  and  up})er  extrem- 
ities. Any  puffiness  or  infiltration  about  the  face  or  any  redema  about 
the  hands  or  arms  should  always  give  rise  to  suspicion  and  lead  to  a 
careful  examination  of  the  urine.  Sometimes  this  is  carried  to  an  exag- 
gerated degree,  so  that  there  is  anasarca  of  the  whole  body. 

Anomalous  nervous  sym])toms — such  as  headache,  transient  dizziness, 
diraiiess,  of  vision,  spots  before  the  eyes,  inability  to  see  objects  dis- 
tinctly, sickness  in  Avomen  not  at  other  times  suffering  from  nausea, 
sleeplessness,  irritabilrty  of  temper — are  also  often  met  with,  sometimes 
to  a  slight  degree,  at  others  very  strongly  developed,  and  should  always 
arouse  suspicion.  Indeed,  knowing  as  we  do  that  many  morbid  states  may 
be  associated  with  albuminuria,  we  should  make  a  point  of  carefully  exam- 

*  Signs  and  Diaaises  of  Pregnancy,  p.  428. 


DISEASES  OF  PREGNANCY.  211 

ining  the  urine  of  all  patients  in  whom  any  unusually  morbid  phenom- 
ena show  themselves  during  pregnancy. 

The  condition  of  the  urine  varies  considerably,  but  it  is  generally 
scanty  and  highly  colored,  and,  in  addition  to  the  albunien.  es[)ecially  in 
cases  in  which  the  albuminuria  has  existed  for  some  time,  we  may  iind 
epithelium  cells,  tube-casts,  and  occasionally  blood-corpuscles. 

Treatment. — The  treatment  must  be  based  on  what  has  been  said  as 
to  the  causes  of  the  albuminuria.  Of  course  it  is  out  of  our  power  to 
remove  the  pressure  of  the  gravid  uterus,  except  by  inducing  labor  ;  but 
its  effects  may  at  least  be  lessened  by  remedies  tending  to  ])romote  an 
UK:]:ei.ig.t;d  secretion  of  urine,  and  thus  diminishing  the  congestion  of  the 
renal  vessels.  The  administration  of  saline  diuretics,  such  as  the  acetate 
ofl4)otash  or  bitartrate  of  potash,  the  latter  being  given  in  the  form  of 
the  well-known  imperial  drink,  will  best  answer  this  indication.  The 
action  of  the  bowels  may  be  solicited  by  purgatives  producing  watery 
motions,  such  as  occasional  doses  of  the  compound  jalap  powder.  Dry 
Clipping  over  the  loins,  frequently  repeated,  has  a  beneficialeffect  in  less- 
ening the  renal  hypersemia.  The  action  of  the  skin  should  also  Be 
promoted  by  the  use  of  the  vapor-bath,  and  with  this  view  the 
Turkish  bath  may  be  employed  with  great  benefit  and  perfect  safety. 
Jaborandi  and  pilocarpin  have  been  given  for  this  purpose,  but  have 
been  found  by  Fordyce  Barker  to  produce  a  dangerous  degree  of  depres- 
sion. The  next  indication  is  to  improve  the  condition  of  the  blood  by 
appropriate  diet  and  medication.  A  very  light  and  easily  assimilated 
diet  should  be  ordered,  of  which  milk  should  form  the  staple.  Tarnier^ 
has  recorded  several  cases  in  which  a  purely  milk  diet  was  very  success- 
ful in  removing  albuminuria.  With  the  milk,  which  should  be  skim- 
med, we  may  allow  white  of  egg  or  a  little  white  fish.  jThe  tincture  of 
the  perchloride  of  iron  is  thel)est  medicine  we  can  give,  and  it  may  be 
advantageously  combined  with  small  doses  of  tincture  of  digitalis,  which 
acts  as  an  excellent  diuretic. 

^  Finally,  in  obstinate  cases  we  shall  have  to  consider  the  advisabilityX 
"•of  inducing  premature  labor.  The  propriety  of  this  procedure  in  thef 
albuminuria  of  pregnancy  has  of  late  years  been  much  discussed. 
Spiegelberg^  is  opposed  to  it,  while  Barker^  thinks  it  should  only  be 
resorted  to  "  when  treatment  has  been  thoroughly  and  perseveringly 
tried  without  success  for  the  removal  of  symptoms  of  so  grave  a  cha- 
racter that  their  continuance  would  result  in  the  death  of  the  patient." 
Hofmeier,*  on  the  other  hand,  is  in  favor  of  the  operation,  which  he 
does  not  think  increases  the  risk  of  eclampsia,  and  may  avert  it  alto- 
gether. I  believe  that,  having  in  view  the  undoubted  risks  which 
attend  this  comj)lication,  the  operation  is  unquestionably  indicated  and 
is  perfectly  justifiable  in  all  cases  attended  with  symptoms  of  serious 
gravity.  It  is  not  easy  to  lay  down  any  definite  rules  to  guide  our 
decision  /  but  I  should  not  hesitate  to  ado]>t  this  resource  in  all  cases  in 
which  tire  quantity  of  all)umen  is  considerable  and  progressively 
increasing,  and  in  which  treatment  has  failed  to  lessen  the  amount  I  and, 
above  all,  in  every  case  attended  with  threatening  symptoms,  such  as 

^  Annal.  de  Oynec,  1876,  torn.  v.  p.  41.  '  Lehrbuch  der  Geburt. 

'  Amer.  Jaiirn.  of  Obstet.,  1878,  vol.  xi.  p.  4-49.  *  Op.  cit. 


212  PREGNANCY. 

severe  hcadaclie,  dizziness,  or  loss  of  si^^l't-  Tlie  risks  of  the  operation 
are  infinitosiinal  compared  to  those  whicli  tiie  patient  would  run  in  tl«e 
event  of  puer|)eral  convulsions  supervening  or  chronic  Bright  s  disease 
becoming  cstahlished.  As  the  operation  is  seldom  likely  to  be  indi- 
cated until  the  diild  has  reached  a  viable  age,  and  as  the  albumimn-ia 
places  the  child's  life  in  danger,  Ave  are  (piite  justified  in  considering  the 
mother's  safety  alone  in  deteriiiining  on  its  perlbrniance. 

Diabetes. — The  occurrence  of  pregnancy  in  a  woman  suffering  from 
diabetes  may  lead  to  serious  consequences,  and  has  recently  been  s])e- 
cially  investigated  by  Dr.  IMatthews  Duncan.'  This  must  be  carefully 
distinguished  from  the  physiological  glycosuria  commonly  present  at 
the  end  of  })regnancy  and  (hiring  lactation.  It  is  probable  that  diabetic 
patients  are  ina])t  to  conceive,  but  A\'hen  ])regnancv  does  occur  under 
such  conditions  the  case  cannot  be  considered  devoid  of  anxiety.  From 
the  cases  collected  by  Dr.  Duncan  it  would  appear  that  pregnancy  is 
very  liable  to  be  interrupted  in  its  course,  generally  by  the  death  of  the 
foetus,  which  has  very  often  occurred.  In  some  instances  no  bad  results 
h'ave  been  observed,  while  in  others  the  patient  has  collajised  after 
delivery.  Diabetic  coma  does  not  seem  to  have  been  observed.  Out 
of  22  pregnancies  in  diabetic  women,  4  ended  fatally,  so  that  the  mor- 
tality is  obviously  very  large.  Too  little  is  known  on  this  subject  to 
justify  positive  rules  of  treatment;  but  if  the  symptoms  are  serious  an( 
increasing  it  would  probably  be  justifiable  to  niduce  labor  ]irematurely 
so  as  to  lessen  the  strain  to  which  the  patient's  constitution  is  sub 
jected. 


CHAPTER  VIII. 

DISEASES  OF  PREGNANCY   (CONTINUED). 

Disorders  of  the  Nervous  System. — There  are  many'disordei's  of 
the  nervous  system  met  with  during  the  course  of  pregnancy.  Among 
the  most  common  are  morbid  irritability  of  tem|)cr,  or  a  state  of  men- 
tal  despondency  and  dread  of  the  resuTts  of  thembor,  sometimes  almost 
amounting  to  insanity  or  even  progressing  to  actual  mania.  These  are 
but  exaggerations  of  the  highly  susceptible  state  of  the  nervous  system 
generally  associated  with  gestation.  AVant_of  jdeej)  is  not  uncommon, 
and  if  carried  to  any  great  extent  may  cause  serious  trouble  from  the 
irritability  and  exhaustion  it  produces.  In  such  cases  we  should* 
endeavor  to  lessen  the  excitable  state  of  the  nerves  by  insisting  on  the 
avoidance  of  late  hours,  overmuch  society,  exciting  anuisemcnts,  and  the 
like;  while  it  may  be  essential  to  promote  sleep  by  the  administration 
of  sedatives,  none  answering  so  well  as  the  chloral  hydrate,  in  combi- 

»  06s/.  Trans.,  1882,  vol.  xxiv.  p.  256. 


DISEASES  OF  PREGNANCY.  2i3 

nation  with  large  doses  of  tlie  bromide  of  potassium  or  sodium,  wliicli 
greatly  intensify  its  hypnotic  effects. 

Severe  headaches  and  various  intense  neuralgias  are  common. 
Amongst  the  latter  the  most  frequently  met  Avith  are  pain  in  the 
breasts,  due  to  the  intimate  sympathetic  connection  of  the  mamnue 
with  the  gravid  uterus,  and  intense  intercostal  neuralgia,  which  a 
careless  observer  might  mistake  for  pleuritic  or  inflammatory  pain. 
The  thermometer,  by  showing  that  there  is  no  elevation  of  tempera- 
ture, would  prevent  such  a  mistake.  Neuralgia  of  the  uterus  itself 
or  severe  pains  in  the  groins  or  thighs — the  latter  being  probably  the 
mechanical  results  of  dragging  on  the  attachments  of  the  abdominal 
muscles — are  also  far  from  uncommon.  (In  the  treatment  of  such  neur- 
algic affections  attention  to  the  state  of  the  general  health  and  large 
doses  of  quinine  and  ferruginous  preparations  whenever  there  is  much 
debility  will  be  indicated,  i  Locally  sedative  applications,  such  as  bella- 
donna and  chloroform  linunents,  fi'ictiou  with  aconite  ointment  when 
the  pain  is  limited  to  a  small  space,  and  in  the  worst  cases  the  subcuta- 
neous injection  of  mor]ihia,  will  be  called  for.  '  Those  pains  which 
apparently  depend  on  mechanical  causes  may  often  be  best  relieved  by 
lessening  the  traction  on  the  muscles  by  wearing  a  Avell-made  elastic 
belt  to  support  the  uterus. 

Paralysis. — Among  the  most  interesting  of  the  nervous  diseases  are 
various  paralytic  aff^ections.  Almost  all  varieties  of  paralysis  have  been 
observed,  such  as  paraplegia,  hemiplegia  (complete  or  incomplete),  facial 
paralysis,  and  paralysis  of  the  nerves  of  special  sense,  giving  rise  to 
amaurosis,  deafness,  and  loss  of  taste,  Churchill  records  22  cases  of 
paralysis  during  pregnancy,  collected  by  him  from  various  sources.  A 
large  number  have  also  been  brought  together  by  Imbert-Goubeyre  in 
an  interesting  memoir  on  the  subject,  and  others  are  recorded  by  For- 
dyce  Barker,  Joulin,  and  other  authors ;  so  that  there  can  be  no  doubt 
of  the  fact  that  paralytic  affections  are  common  during  gestation.  In  a 
large  proportion  of  the  cases  recorded  the  jjaralyses  have  been  asso- 
ciated with  albuminuria,  and  are  doubtless  ursemic  in  origin.  Thus  in 
19  cases  related  by  Goubeyre  albuminuria  was  present  in  all;  Darcy,^ 
however,  found  no  albuminuria  in  5  out  of  14  cases.  The  dependency 
of  the  paralysis  on  a  transient  cause  explains  the  fact  that  in  the  large 
majority  of  these  cases  the  paralysis  was  not  permanent,  but  disap- 
peared shortly  after  labor.  In  every  case  of  paralysis,  whatever  be  its 
nature,  special  attention  should  be  directed  to  the  state  of  the  urine,  and 
should  it  be  found  to  be  albuminous  labor  should  be  at  once  induced. 
This  is  clearly  the  ])roper  coui'so  to  pursue,  and  we  should  certainly  not 
be  justified  in  running  the  risk  that  must  attend  the  progress  of  a  case 
in  which  so  formidable  a  symptom  has  already  developed  itself.  ^Mieu 
the  cause  has  been  removed  the  effect  Avill  also  genei'ally  rapidly  disaji- 
pear,  and  the  prognosis  is  therefore,  on  the  whole,  favorable.  Should 
the  ))aralysis  continue  after  delivery,  the  treatment  must  be  such  as  we 
would  adopt  in  the  non-pregnant  state,  and  small  doses  of  strychnia, 
along  with  faradization  of  the  affected  limbs,  would  be  the  best  reme- 
dies at  our  disposal. 

1  These  de  Pari.%  1877. 


214  Pli  EG  NANCY. 

There  are,  liowevcr,  unquestionably  some  cases  of  j)uerj)eral  paraly- 
■;is  Avhicli  are  not  unoniic  in  their  ori<rin,  and  the  nature  of  Avhieh  is 
somewhat  ohseure.  IIeini|)k'g;ia  may  doubtless  be  occasioned  by  cei-e- 
bral  iieni()rrha<i-e,  as  in  the  non-prej^nant  state.  Other  or<i;anic  causes 
of  ]>aralysis,  .-^ueh  as  cerebral  c(m<:estion  or  embolism,  may,  now  and 
a_i!;ain,  be  met  uilli  dtiiiiiii-  j)regnancy,  but  cases  of  this  kind  uuist  be  of 
comparative  rarity.  Other  cases  are  functional  in  their  origin.  Tarnier 
relates  a  case  of  hemiplegia  which  he  could  only  refer  to  extreme  ana?- 
nu'a.  Some,  again,  may  be  hyslei'ical.  Parai)legia  is  a))parenlly  more\ 
frequently  uneoinieeted  with  albuminuria  than  the  other  foi-ms  of  ])aralv-' 
sis;  and  it  may  eithei-  dej)end  on  pi-essure  of  the  gi'avid  uterus  on  tlie 
uervcs  as  they  })ass  through  the  pelvis,  or  on  rcHex  action,  as  is  some- 
times observed  in  connection  with  uterine  disease.  A\'hen,  in  such 
cases,  the  absence  of  albuminuria  is  ascertained  by  frequent  examination 
of  the  urine,  there  is  obviously  not  the  same  risk  to  the  ])atient  as  in 
cases  depending  on  urjcmia,  and  therefore  it  may  be  justifiable  to  allow 
pregnancy  to  go  on  to  term,  trusting  to  subsequent  general  treatment  to 
remove  the  paralytic  sym])toms.  As  the  loss  of  power  here  depends  on 
a  transient  cause,  a  favorable  prognosis  is  quite  justifiable.  Partial  })ar- 
alysis  of  one  lower  extremity,  generally  the  left,  sometimes  occurs  from 
pressure  of  the  ftetal  occiput,  and  may  continue  fur  days  or  weeks,  with 
a  gradual  improvement  after  ])arturition. 

Chorea. — Chorea  is  not  infrequently  observed,  and  forms  a  serious 
com])lication.  It  is  generally  met  with  in  young  women  of  delicate 
health  and  in  the  first  pregnancy.  In  a  large  projiortion  of  the  ca.ses 
the  patient  has  already  suffered  from  the  disease  befoi-e  marriage.  On 
the  occurrence  of  pregnancy  the  disposition  to  the  disease  again  becomes 
evoked,  and  choreic  movements  are  re-established.  This  fact  may  be 
explained  partly  by  the  susceptible  state  of  the  nervous  system,  jiartly 
by  the  impoverished  condition  of  the  blood. 

Prognosis. — That  chorea  is  a  dangerous  comjilication  of  ])regnancy 
is  ajijiarent  by  the  fact  that  out  of  56  cases  collected  by  Dr.  Barnes'  no 
less  than  17,  or  1  in  3,  })roved  fatal.  Nor  is  it  danger  to  life  alone  that 
is  to  be  feared,  for  it  appears  certain  that  chorea  is  more  apt  to  leave 
permanent  mental  disturbance  when  it  occurs  during  ])regnau(y  than  at 
other  times.  Jt  has  also  an  unquestionable  tendency  to  bi'ing  on  abor- 
tion or  premature  labor,  and  in  most  cases  the  life  of  the  v\u\d  is 
sacrificed. 

Treatment. — Tlie  treatment  ot"  chorea  during  ])regnancy  does  not 
differ  from  that  of  the  disease  under  more  ordinary  circumstances,  and 
our  chief  reliance  Avill  be  ])laced  on  such  drugs  as  the  licpior  arseuicalis, 
brnmide  of  potassium,  and  iron.  In  the  severe  form  of  the  disease  the 
incessant  movements  and  the  weariness  and  loss  of  sleep  may  very 
seriously  imjieril  the  life  of  the  patient,  and  more  prompt  and  radical 
measures  will  l)e  indicated.  (If,  in  spite  of  our  remedies,  the  parox- 
vsms  go  on  increasing  in  severity,  and  the  patient's  strength  apjx'ai's  to 
be  exhausted,  f)ur  oidy  resource  is  to  remove  the  most  evident  cause  by 
inducing  labor,  s  Generally  the  symptoms  lessen  and  disa]>j)ear  soon 
after  this  is  dune.     There  can  be  no  question  tliat  the  operation  is  per- 

'  Obd.  Trans.,  ISGH,  vol.  x.  \k  147. 


DISEASES  OF  PREGNANCY.  215 

feotly  jiistifiiil)]e,  an<l  may  even  be  essential  under  such  oircumstances. 
It  should  he  borne  in  mind  that  the  chorea  often  recurs  in  a  subsequent 
pregnancy,  and  extra  care  should  then  always  be  taken  t<j  prevent 
its  developmeat. 

Tetanus. — Tetanus  has  not  infrequently  been  observed  in  connection 
with  pregnancy  in  the  tropics,  where  the  disease  is  common.  In  tem- 
perate climates  it  is  exceedingly  rare,  and  has  been  more  often  met  with 
after  abortion  than  after  labor  at  term.  Little  is  known  of  this  com- 
plication of  pregnancy,  either  as  to  its  causation  or  of  the  modification 
of  the  symptoms  which  may  show  themselves.  The  risk  to  the  patient, 
however,  is  very  great.  Out  of  30  cases  recorded — 28  by  Simpson,  2 
by  Wiltshire — only  6  recovered. 

Disorders  of  the  Urinary  Organs. — Retention  of  the  Urine. — 
Disorders  of  the  urinary  organs  are  of  frequent  occurrence.  Retention 
Q^jLiriue  may  be  met  with,  and  this  is  often  the  result  of  a  retrovertecl 
uterus.  The  treatment,  therefore,  must  then  be  directed  to  the  removal 
of  the  cause.  This  subject  will  be  more  particularly  considered  when 
we  come  to  discuss  that  form  of  displacement  (p.  219);  but  we  may 
here  point  out  that  retention  of  urine,  if  long  continued,  may  not  only 
lead  to  much  distress,  but  to  actual  disease  of  the  coats  of  the  l)ladder. 
Several  cases  have  been  recorded  in  which  cystitis,  resulting  from  uri- 
nary retention  in  pregnancy,  eventually  caused  the  exfoliation  of  the 
entire  mucous  membrane  of  the  bladder,^  which  was  cast  off,  sometimes 
entire,  sometimes  in  shreds^  and  occasionally  with  portions  of  the  mus- 
cular coat  attached  to  it.  ]  The  possibility  of  this  formidable  accident; 
should  teach  us  to  be  careful  not  to  allow  any  undue  retention  of  urine, 
but  by  a  timely  use  of  the  catheter  to  relieve  the  symptoms,  while  we, 
at  the  same  time,  endeavor  to  remove  the  cause.\ 

.Irritability  of  the  bladder  is  of  frequent  occurrence^.  In  the  early 
mouths  it  seems  to  be  the  consequence  of  sympathetic  irritation  of  the 
neck  of  the  bladder,  combined  with  pressure,  while  in  the  later  months 
it  is  probably  solely  produced  by  mechanical  causes.  When  severe  it 
leads  to  much  distress,  the  patient's  rest  being  broken  and  disturbed  by 
incessant  calls  to  micturate,  and  the  suffering  induced  may  produce 
serious  constitutional  disturbances.  I  have  elsewhere  pointed  out^  that 
irritability  of  the  bladder  in  the  later  months  of  pregnancy  is  frequently 
associated  with  an  abnormal  position  of  the  fcetus,  Avhich  is  placed  trans- 
versely or  obliquely.  The  result  is  either  that  undue  pressure  is  applied 
to  the  bladder  or  that  it  is  drawn  out  of  its  proper  position.  The 
abnormal  ]Josition  of  the  foetus  can  readily  be  detected  by  palpation, 
and  is  readily  altered  by  external  manipulation.  In  some  of  the  cases 
I  have  recorded  altering-  the  position  of  the  foetus  was  immediately  fol- 
lowed by  relief,  the  syin])toms  recurring  after  a  time  when  the  f(Ptus 
had  again  resumed  an  oblique  position.  Should  the  foetus  frequently 
become  displaced,  an  endeavor  may  be  made  to  retain  it  in  the  longitu- 
dinal axis  of  the  uterus  by  a  proper  adaj)tation  of  bandages  or  pads. 
In  cases  not  referable  to  this  cause  w^e  should  attempt  to  relieve  the 
bladder  symptoms  by  appropriate  medication,  such  as  small  doses  of 
liquor  potassre  if  the  urine  be  very  acid  ;  tincture  of  Jielladonna  ;  the 

1  06s/.  Trans.,  1863,  vol.  iv.  p.  13.  ^  jr^,-j^  is72,  vol.  xiii.  p.  42. 


216  J'Jii:(;.\A.\ci'. 

(Icctiction  of  triticniu  ro pons,  an  old  l)iit  vcrv  scrvicealjlc  rcmwlv  ;  and 
va<;iiial  st'dativc  ju'ssarics  cuntaiiiin':;  inoipliia  or  atropine. 

[In  one  case  under  tlie  eare  of"  the  uriter  the  constant  calls  to 
urinate  Avere  due  to  the  })ressure  produced  by  the  dei'er-tive  head  of 
an  aueueeplialous  foetus.  Fortunately,  relief  came  in  a  miscarriage 
at  seven  months. — Ed.] 

AVomen  who  have  borne  many  children  are  often  troubbd  with 
incontinence  of  urine  during  pregnancy,  the  water  dribbling  away 
on  the  slightest  movement.  Through  this  nuich  iri'itation  of  the  skin 
surrounding  the  genitals  is  ])roduced,  attended  with  troublesome  excor- 
iations and  eruptions.  Kelief  may  be  partially  obtained  by  lessening 
the  ju-essure  ©n  the  bladder  by  an  abdominal  belt,  wliile  the  skin  is 
protected  by  applications  of  simple  ointment  or  glycerin. 

Dr.  Tyler  Smith  has  directed  attention  to  a  phosphatic  condition 
of  the  urine  occurring  in  delicate  women,  Avhose  constitutions  are 
severely  tried  by  gestation.  This  condition  can  easily  be  altered  by 
rest,  nutritious  diet,  and  a  course  of  restorative  medicines,  such  as 
steel,  mineral  acids,  and  the  like. 

Leucorrhoea. — A  profuse  whitish  leucorrhceal  discharge  is  very 
common  during  pregnancy,  es])eeially  in  its  latter  half.  The  disciiarge 
frequently  alarms  the  patient,  but  unless  it  is  attended  with  disagreeable 
symj)toms  it  does  not  call  for  special  treatment j  When  at  all  excessive 
it  may  lead  to  much  irritation  of  the  vagina  and  external  generative 
organs.  The  labia  may  become  excoriated  and  covered  with  small  aj)h- 
thous  patches,  and  the  Avhole  vulva  may  be  hot,  swollen,  and  tender. 
AVarty  growths,  similar  in  appearance  to  syphilitic  condylonuita,  are 
occasionally  develo])ed  in  pregnant  women,  miconnected  with  any  spe- 
cific taint  and  associated  with  the  presence  of  an  irritating  leucorrlneal 
discharge.  According  to  Thibierge,^  these  resist  local  appliciitions,  such 
as  sul])hate  of  cop])er  or  nitrate  of  silver,  but  spontaneously  disa])pear 
after  delivery.  Inasmuch  as  the  leucorrhceal  discharge  is  dependent  on 
the  congested  condition  of  the  generative  organs  accompanying  preg- 
nancy, we  can  hope  to  do  little  more  than  alleviate  it.  In  the  severer 
forms,  as  has  been  pointed  out  by  Henry  Bennet,  the  cervix  will  be 
found  to  be  abraded  or  covered  with  granular  erosion,  and  it  may  be 
from  time  to  time  cautiously  touched  with  the  ultimate  of  silver  or  a 
solution  of  carbolic  acid.  Generally  speaking,  we  nnist  content  our- 
selves with  /recommending  the  patieirt  to  Mash  the  vagina  out  gently 
with  diluted  Condy's  fluid,  or  with  a  solution  of  the  sulpho-carl)olate 
of  zinc  of  the  strength  of  four  grains  to  the  ounce  of  water,  or  with 
])lain  tepid  water.  For  obvious  reasons,  frequent  and  strong  vaginal 
douches  are  to  be  avoided,  but  a  daily  gentle  injection  for  the  ]iur- 
pose  of  abluti(m  can  do  no  harm. 

Pruritus. — A  very  distressing  pruritus  of  the  vulva  is  frequeiuly 
met  with  along  with  leucorrhcea,  especially  when  the  discharge  is  of  an 
acrid  character,  which  in  some  cases  leads  to  intense  and  protracted  suf- 
fering, forcing  the  ])atient  to  resort  to  incessant  friction  of  the  ])arts. 
Pruritus,  however,  may  exist  without  leucorrhoea,  being  ap]>arently 
sometimes  of  a  neuralgic  character,  at  othei"s  associated  with  aphthous 

'  Arch.  gen.  de  Med.,  1856. 


DISEASES  OF  rREG NANCY.  217 

patches  on  the  iniK'ou.s  luembmne,  ascaridcs  in  the  rectum,  or  pediculi 
in  the  Juiii-s  oC  the  mens  Veneris  and  labia.  Cases  are  even  recorded 
in  which  the  pruritic  irritation  extended  over  the  whole  Ixxly.  (Tlic 
trcatniejit  is  ditHcult  and  unsatisla(;toryi  Various  sedative  a])plications 
may  be  tried,  such  as  weak  solutions  of  Goulard's  lotion,  oi{  a  lotion 
composed  of  an  ounce  of  the  solution  of  the  nnu-iate  of  niorphia, 
with  a  drachm  and  a  half  of  hydrocyanic  acid,  in  six  ounces  of 
watei\|  or  lone  formed  by  mixing  one  part  of  chloroform  with  six  of 
almond  oil.)  [A  very  useful  form  of  medicatioii  consists  in  the  insertion 
into  the  vagina  of  a  pledget  of  cotton-wool  soaked  in  equal  parts  of  the 
glycerin  of  borax  and  sulphurous  acid;  this  may  be  inserted  at  bedtime, 
and  withdrawn  in  the  morning  by  means  of  a  string  attached  to  it.  < 
Smearing  the  parts  with  an  ointment  consisting  of  boracic  acid  and  | 
vaseline  often  answers  admirably.  In  the  more  obstinate  cases  the 
solid  nitrate  of  silver  may  be  lightly  brushed  over  the  vulva,  or,  as 
recommended  by  Tarnier,  a  solution  of  bichloride  of  mercury,  of  about 
the  strength  of  two  grains  to  the  ounce,  may  be  applied  night  and 
morning.  The  state  of  the  digestive  organs  should  always  be  attended 
to,  and  aperient  mineral  water  may  be  usefully  administered.  When 
the  pruritus  extends  beyond  the  vulva,  or  even  in  severe  local  cases, 
large  doses  of  bromide  of  potassium  may  perhaps  be  useful  in  lessening 
the  general  hyperpesthetic  state  of  the  nerves. 

GEdema  of  the  Lower  Limbs. — Some  of  the  disorders  of  pregnancy 
are  the  direct  results  of  the  mechanical  pressure  of  the  gravid  uterus. 
The  most  common  of  these  are  ced_eraa  and  a  varicose  state  of  the 
j^ns  .of..th,a-lawer._extremities,  or  even  of  the  vulva.  The  former 
is  of  little  consequence,  provided  Ave  have  assured  ourselves  that  it  is 
really  the  result  of  j^ressure,  and  not  of  albuminuria,  and  it  can  gener- 
ally be  relieved  by  rest  in  the  horizontal  position.  A  varicose  state  of 
the  veins  of  the  lower  limbs  is  very  common,  especially  in  multiparae, 
in  whom  it  is  apt  to  continue  after  delivery.  The  varicosity  is  gener- 
ally limited  to  the  superficial  veins,  chiefly  the  saphena,  ancl  the  veins 
on  the  inner  surface  of  the  leg  and  thigh ;  sometimes  the  deeper  veins 
are  also  aifected,  and  this  is  said  to  be  accompanied  by  severe  pain  in 
the  sole  of  the  foot  when  the  patient  is  standing  or  walking.  Occasion-| 
ally  the  veins  of  the  vulva,  and  even  of  the  vagina,  are  also  enlarged^ 
and  varicose,  producing  considerable  swelling  of  the  external  genitals. | 
Rest  in  the  recumbent  position  and  the  use  of  an  abdominal  belt,  so  as 
to  take  the  pressure  off  the  veins  as  much  as  possible,  are  all  that  can 
be  done  to  relieve  this  troublesome  complication.  If  the  veins  ofj 
the  legs  are  much  swollen  some  benefit  may  be  derived  from  an  elas-} 
tic  stocking  or  a  carefully  applied  bandage. 

Laceration  of  the  Veins. — Serious  and  even  fatal  consequences  have 
followed  the  accidental  laceration  of  the  swollen  veins.  When  lacera- 
tion occurs  during  or  immediately  after  delivery — a  not  uncommon 
result  of  the  pressure  of  the  head — it  gives  rise  to  the  formation  of  a 
vaginal  thrombus.  It  has  occasionally  happened  from  an  accidental 
injury  during  pregnancy,  as  in  the  cases  recorded  by  Simpson,  in  which 
death  followed  a  kick  on  the  pudenda,  producing  laceration  of  a  vari- 
cose vein,  or  in  one  mentioned  by  Tarnier,  where  the  patient  fell  on  the 


218  rRKayAycv. 

t'do;o()f  a  chair,  Sevoiv  liciuoirliatic  has  lollowcd  the  acrcidcntal  ni)>tiire 
of  a  vein  in  the  h-g.  Tiic  only  .sitisltu-tory  ti-catiiiciit  i.s  prcssurt',  a|t- 
|)liccl  directly  to  the  hleediiitr  |)arts  hy  means  of  tlie  Hn<rer  or  by 
com  presses  saturated  in  a  sohition  of  the  j)erchU)ri(le  of"  iron.  The 
treatment  of  vajrinal  thrombus  followinii;  hiljor  must  be  considenHl 
elsewhere.  Occasionally  the  varicose  veins  inflame,  become  very  tender 
and  painful,  and  eoatiula  form  in  their  canals.  In  such  cases  al)solute 
rest  shoidd  be  insisted  on,  while  sedative  lotions,  such  as  the  chloro- 
form anil  belladt)nna  liniments,  should  i)e  ap])lied  to  relieve  the  i»aiu. 

Displacements  of  the  Gravid  Uterus. — Certain  disj)lacen)ents  of 
the  gravid  uterus  are  met  with  which  may  give  rise  to  symptoms  of 
great  gravity. 
/  Prolapse,  m  liich  is  rare,  is  almost  always  the  I'esidt  of  pregnancy 
occurring  in  a  uterus  Avhich  had  been  })reviously  more  or  less  pro- 
cident./  Under  such  circumstances  the  increasing  weight  of  the  uterus 
Avill  at  first  necessarily  augment  the  previously  existing  tendency  to  pro- 
lapse of  the  womb,  A\diicli  may  come  to  protrude  partially  and  entirely 
beyond  the  vulva.  Tin  the  great  majority  of  cases,  as  pregnancy 
advances,  the  prolapse  cures  itself,  for  at  about  the  ioiu-th  or  fifth  month 
the  uterus  will  rise  above  the  pelvic  brim.)  It  has  been  said  that  in 
some  cases  of  complete  procidentia  pregnancy  has  gone  even  to  term, 
Avith  tlie  uterus  lying  entirely  outside  the  vulva.  Most  ]»robably  these 
cases  were  imperfectly  observed,  the  greater  part  of  the  uterus  being  in 
reality  above  the  pelvic  brim,  a  portion  only  of  its  lower  segment  pro- 
truding externally ;  or,  as  has  sometimes  been  the  case,  the  protruding 
portion  has  been  an  old-standing  hyi)ertrophic  elongation  of  the  cervix, 
the  internal  os  uteri  and  fundus  being  normally  situated.  Should  a  pro-/ 
lapsed  uterus  not  rise  into  the  abdominal  cavity  as  })regiiancy  advances, 
serious  symptoms  will  be  apt  to  develop  themselves;  for  mdess  the  ])el-  , 
vis  be  unusually  capacious  the  enlarging  uterus  will  get  jammed  within 
its  bony  walls,  the  rectum  and  urethra  Mill  be  pressed  upon,  defecation 
and  micturition  will  be  consequently  impeded,  and  severe  pain  and 
much  irritation  will  result,  sin  all  ])robability  such  a  state  of  things 
Avould  lead  to  abortion.  The  ])ossibility  of  these  consecjuences  should 
therefore  teach  us  to  be  careful  in  the  management  of  every  case  of  pro- 
lapse, however  slight,  in  which  ]iregnancy  occurs.  Absolute  rest  in  the 
horizontal  position  should  be  insisted  on,  while  the  uterus  should  lie  sup- 
ported in  the  ]Kdvis  by  a  full-sized  Hodge's  pessary,  which  shoidd  be 
M'orn  until  at  least  the  sixth  month,  when  the  uterus  would  l)c  fully 
Avithin  the  abdominal  cavity.  After  delivery  proh)nged  rest  should  be 
recommended,  in  the  hope  that  the  ])rocessof  involution  may  be  accom- 
panied by  a  cure  of  the  prolapse.  There  can  l)e  no  doubt  tliat  jircg- 
uancv  carried  to  term  affords  an  opportunity  of  curing  even  old-stand- 
ing disjtlacements  which  should  not  be  neglected. 

Anteversion  of  the  gravid  uterus^^seldom  pniduccs  sym]>toms  of 
consequence.  \  In  all  ])rol)ability  it  is  common  enough  when  jiregnancv 
occurs  in  a  uterus  which  is  more  than  usually  antevertcd  or  is  anteflexed. 
Under  such  circumstances  there  is  not  the  same  risk  of  incarceration  in 
the  pelvic  cavity  as  in  cases  in  Avhich  pregnancy  exists  in  a  retroflexcd 
uterus,  for  as  the  uterus   increases   in   size  it  rises  without  difliculty 


DISEASES  OF  PREGNANCY.  219 

into  the  alxloniiiiul  cavity.      Fn  the  oai'ly  months  the  pressure  of  thej 
fundus  on  the  hhulder  may  account  for  the  irrital)ility  of  tliat  viscus 
then  so  commonly  observed.    It  will  be  remembered  that  Graily  Hewitt! 
attributes  great  importance  to  this  condition  as  explaining  the  sickness 
of  ])regnuncy — a  theory,  however,  which  has  not  met  with  general 
acceptation. 

Extreme  anteversion  of  the  uterus  at  an  advanced  })cri()(!  of  i)reg- 
nancy  is  sometimes  observed  in  multipanc  with  very  lax  abdominal 
walls,  occasionally  to  such  an  extent  that  the  uterus  falls  completely 
forward  and  downward,  so  that  the  fundus  is  almost  on  a  level  with 
the  patient's  knees.  This  form  of  pendulous  belly  niay  be  associated 
with  a  separation  of  the  recti  muscles,  between  which  the  womb  forms 
a  ventral  hernia  covered  only  by  the  cutaneous  textures.  When  labor 
comes  on  this  variety  of  displacement  may  give  rise  to  trouble  by  de- 
stroying the  proper  relation  of  the  uterine  and  pelvic  axes.  The_ii'eat- 
ment  is  purely  mechanical^  keeping  the  patient  lying  on  her  back  as 
much  as  possible  and  supporting  the  pendulous  abdomen  by  a  proi)erly 
adjusted  bandage.  A  similar  forward  displacement  is  observed  in  cases 
of  pelvic  deformity,  and  in  the  worst  forms  in  rachitic  and  dwarfed 
Avomen  it  exists  to  a  very  exaggerated  degree. 

The  most  important  of  the  displacements,  in  consequence  of  its 
occasional  very  serious  results,  is  retroversion  of  the  gravid  uterus. 
It  was  formerly  generally  believed  that  this  was  most  commonly  pro- 
duced by  some  accident,  such  as  a  fall,  which  dislocated  a  uterus  pre- 
viously in  a  normal  position.  Undue  distension  of  the  bladder  was 
also  considered  to  have  an  important  influence  in  its  production  by 
pressing  the  uterus  backward  and  downward. 

Causes. — It  is  now  almost  universally  admitted  that,  although  the 
above-named  causes  may  possibly  sometimes  produce  it,  in  the  very  large 
proportion  of  cases /it  depends  on  pregnancy  having  occurred  in  a 
uterus  previously  reh'overted  or  retroflexed.j  Tlie  merit  of  pointing 
out  this  fact  unquestionably  belongs  to  tire  late  Dr.  Tyler  Smith, 
and  further  observations  have  fully  corroborated  the  correctness  of 
his  views. 

In  the  large  majority  of  cases  in  which  pregnancy  occurs  in  a  uterus 
so  displaced,  as  the  womb  enlarges  it  straighj£ns,.itaelf  and  rises  into  the 
abdominal  cavity,  M-ithout  giving  any  particular  trouble;  or,  as  not 
unfrequently  happens,  the  abnormal  ]>osition  of  the  organ  interferes  so 
much  with  its  enlargement  as  to  prqduce-jabortion.  Sometimes,  ho^v- 
ever,  the  uterus  increases  without  leaving  the  pelvis  until  the  third  or 
fourth  month,  when  it  can  no  longer  be  retained  in  the  pelvic  cavity 
without  inconvenience.  It  then  presses  on  the  urethra  and  rectum,  and 
eventually  becomes  completely  incarcerated  within  the  rigid  walls  of  the 
bony  jK'lvis,  giving  rise  to  characteristic  sym])toms. 

Symptoms. — The  first  sign  which  attracts  attention  is  generally 
some  trouble  connected  with  micturition,  in  consequence  of  pressure  on 
the  urethra!  On  examination  the  bladder  will  often  be  found  to  be 
enormously  distended,  forming  a  large,  fluctuating  abdominal  tumor 
M'hich  the  patient  has  lost  all  power  of  emptying.  Frequently  small 
quantities  of  urine  dribble  away,  leading  the  woman  to  believe  that  she 


220  rnhayAycY. 

has  |)ass('(l  water,  aii<l  tlms  (lie  distensioii  is  often  overlooked.  Soine- 
tiiiies  the  ohstriiction  !<•  the  disehai'i^e  of  urine  is  so  <i;reat  as  to  lead  to 
dro|)sieaI  elfiisioii  intct  the  cellular  tissue  of  the  ai'iiis  and  le<:s.  This 
was  vej-y  well  iiiarketT  in  one  of  iuy  cases,  aiicl  disapjieamTTajmlly  after 
the  hladdci-  had  been  enij»tied.  DiHicultv  iu  defecation,  tenesnuis. 
•  ihstinaj^i' constipation,  and  inahility  U>  empty  the  bowels  "licconie  estab- 
lished al)(»nt  the  san)e  time.  These  symptoms  increase,  accom|)anie(l  by 
some  pelvic  i)ain  and  a  sense  of  wei<i;ht  and  bearin<r  down,  until  at  last 
the  j)atient  ap])lies  for  advice  and  the  true  nature  of  the  case  is  detected, 
A\'hen  the  retrovei'sion  occui-s  suddenly  all  these  symj)toms  devcloj)  witli 
gi'eat  ra])idity,  and  are  sometimes  very  serious  from  the  first. 

Progress  and  Termination. — The  further  pro<rress  is  vai-ious. 
Sometimes,  after  the  uterus  has  been  ineareerated  in  the  i)elvis  for  more 
or  less  time,  it  may  sjjontaneously  rise  into  the  abdominal  cavity,  when 
all  threatening  symptoms  will  disa))pear.  So  hap])v  a  termination  is 
quite  exceptional,  and  should  the  practitioner  not  interfere  and  etiect 
re])osition  of  the  organ,  serious  and  even  fatal  consequences  may  ensue, 
unless  abortion  occurs. 

The  extreme  distension  of  the  bladder,  and  the  impossibility  of 
relieving  it,  may  lead  to  laceration  of  its  coats  and  fatal  peritonitis;  or 
the  retention  of  urine  may  produce  cystitis,  with  exfoliation  of  the  coats 
of  the  bladder;  or,  as  more  commonly  hai)pens,  retention  of  urinary 
elements  may  take  place,  and  death  occur  with  all  the  symptoms  of 
urremic  poisoning.  At  other  times  the  impacted  uterus  becomes  con- 
gested and  inflamed,  and  eventually  sloughs,  its  contents,  if  the  patient 
survive,  being  discharged  by  fistulous  communications  into  the  rectum 
and  vagina.  It  need  hardlv  be  said  that  such  ternu'nations  are  onlv 
possible  iu  cases  which  have  been  grossly  mismanaged  or  the  nature  of 
which  has  not  been  detected  till  a  late  ])eriod. 

Diagnosis. — The  diagnosis  is  not  difficult.  On  making  a  vaginal 
examination  the  finger  impinges  on  a  smooth,  round,  elastic  swelling 
filling  up  the  lower  part  of  the  pelvis,  stretching  and  de])i-essing  the 
]>osterior  vaginal  wall,  which  occasionally  ])rotrudes  beyond  the  vulva. 
On  ])assing  the  finger  forward  and  upward  we  shall  generally  be  able  to 
reach  the  cervix,  high  up  behind  the  pubes  and  pressing  on  the  ure- 
thral canal.  In  very  complete  retroversion  it  may  be  difficult  or  impos- 
sible to  reach  the  cervix  at  all.  .  On  abdominal  examination  the  fundus 
uteri  cannot  be  felt  above  the  pelvic  brim  i  this,  as  the  retroversion  docs 
not  give  rise  to  serious  symptoms  until  between  the  third  and  fbiyth 
months,  should,  under  natural  circumstances,  always  be  possible.  (By 
l)imanual  examination  we  can  make  out,  with  due  care,  the  alternate 
relaxation  and  contraction  of  the  uterine  parietes  characteristic  of  the 
gravid  uterus,  and  so  differentiate  the  swelling  from  any  other  in  the 
same  situation^  The  accomjxuiving  ])henomcna  of  ]>regnancy  will  also 
prevent  any  mistake  of  this  kind. 

In  some  few  cases  retroversion  has  been  supposed  to  go  on  to  term. 
Strictly  speaking,  this  is  impossible;  but  in  the  su]i])osed  examples, 
such  as  the  well-known  case  recorded  by  Oldham,  part  of  a  retroflexed 
uterus  remained  in  the  pelvic  cavity,  while  the  greater  ]>art  developed 
in  the  abdominal  cavitv.     The  uterus  is  therefore  divided,  as  it  were, 


DISEASES  OF  PREGNANCY.  221 

into  two  portions — one,  Avliicli  is  the  flexed  finulns,  remaining  in  the 
pelvis,  the  otiier,  containint;'  tlie  greater  part  of  tlie  fVetns,  rising  above 
it.  Under  these  eircnnistanees  a  tumor  in  the  vagina  would  exist  in 
combination  with  an  abdominal  tumor,  and  pregnancy  might  go  on  to 
term.  Considerable  difficulty  may  even  arise  in  labor,  but  the  malpo- 
sition generally  rectifies  itself  before  it  gives  rise  to  any  serious  residts. 

Treatment. — Tlie  treatment  of  retroversion  of  the  gravid  uterus 
should  be  taken  in  hand  as  soon  as  possible,  for  every  day's  delay 
involves  an  increase  in  the  size  of  the  uterus,  and  leads,  therefore,  to 
greater  difficulty  in  reposition.  Our  object  is  to  restore  the  natural 
direction  of  the  uterus  by  lifting  the  fundus  above  the  promontory  of 
the  sacrum.  The  first  thing  to  be  done  is  to  relieve  the  patient  by 
emptying-  the  bladder,  the  retention  of  urine  having  probably  originally 
called  attention  to  the  case.  For  this  purpose  it  is  essential  to  use  a  long 
elastic  male  catheter  of  small  size,  as  the  urethra  is  too  elongated  and 
compressed  to  admit  of  the  passage  of  the  ordinary  silver  instrument. 
Even  then  it  may  be  extremely  difficult  to  introduce  the  catheter,  and 
sometimes  it  has  been  found  to  be  quite  impossible.  Under  such  cir- 
cumstances, provided  reposition  cannot  be  effected  without  it,  the  bladder 
may  be  punctured  an  inch  or  two  above  the  pubes  by  means  of  the  fine 
needle  of  an  aspirator,  and  the  urine  drawn  off.  Dieulafoy's  work  on 
aspiration  proves  conclusively  that  this  may  be  done  without  risk,  and 
the  operation  has  been  successfully  performed  by  Schatz  and  others.  It 
very  rarely  happens,  hoAvever,  and  in  long-neglected  cases  ouly,  that  the 
withdrawal  of  the  urine  is  found  to  be  impossible. 

The  bladder  being  emptied,  and  the  bowels  being  also  opened,  if  pos- 
sible, by  copious  enemata,  we  proceed  to.  attempt  reduction.  For  this 
purpose  various  procedures  are  adopted.  (  If  the  case  is  not  of  very  long 
standing,  I  am  inclined  to  think  that  the  gentlest  and  safest  plan  is  the 
continuous  pressure  of  a  caoutchouc  bag,  filled  with  water,  placed  in  the 
vagina.  \  The  good  effect  of  steady  and  long-continued  pressure  of  this 
kind  was  proved  by  Tyler  Smith,  who  effected  in  this  way  the  reduction 
of  an  inverted  uterus  of  long  standing,  and  it  is  not  difficult  to  under- 
stand that  it  may  succeed  when  a  more  sudden  and  violent  effort  fails. 
I  have  tried  this  plan  successfully  in  two  cases,  a  pyriform  india-rubber 
bag  being  inserted  into  the  vagina  and  distended  as  far  as  the  patient 
could  bear  by  means  of  a  syringe.  The  Avater  must  be  let  out  occasion- 
ally to  allow  the  patient  to  empty  the  bladder,  and  the  bag  immediately 
refilled.  In  both  my  cases  reposition  occurred  within  twenty-four 
hours.  Barnes  has  failed  with  this  method  ;  but  it  succeeded  so  Avell  in 
my  cases,  and  is  so  obviously  less  likely  to  prove  hurtful  than  forcible 
reposition  with  the  hand,  that  I  am  inclined  to  consider  it  the  prefer-_ 
able  procedure  and  one  that  should  be  tried  first.  (Failing  with  the 
fluid  pressure,  we  should  endeavor  to  replace  the  uterus' in  the  following 
way:  The  patient  should  be  placed  at  the  edge  of  the  bed  in  the  ordi-1 
nary  obstetric  position,  and  thoroughly  ana?sthetizcd.  This  is  of  import- 
ance, as  it  relaxes  all  the  parts  and  admits  of  much  freer  manipulation 
than  is  otherwise  possible.  One  or  more  fingers  of  the  left  hand  are 
then  inserted  into  the  rectum — if  the  patient  be  deeply  chloroformed  it 
is  quite  possible,  with  due  care,  even  to  pass  the  whole  hand — and  an 


222  PREGNAycv. 

attempt  is  tlien  iiiadi'  to  lift  or  j)ush  tlic  ("uikIus  above  the  promontory 
of  the  sacniin.  At  the  same  time  iej)ositioii  is  aided  bv  chawinji;  down 
tlie  cervix  witli  tiie  tin«iers  of  the  ri<2;ht  hand  j/cr  luu/iiKnn.  It  has  been 
insisted  tiiat  the  jiressnre  shoidd  be  made  in  the  direction  of  one  or  other 
saero-iliac  synchondrosis  I'ather  than  directly  npward,  so  that  the  uterus 
may  not  be  jammed  against  the  j)rojectiou  of  the  promontory  of  tlie 
sacrum.  Failing  reposition  througli  the  rectum,  an  attempt  may  be 
madeyyr/'  r(i(/iii(i/it,  and  for  this  some  liave  advised  the  uj)\\ard  |)r(ssnre  of 
the  closed  fist  passed  into  the  canal.  (Others  reeonnnend  the  hand-and- 
knee  position  as  facilitating  rej)osition,  but  this  prevents  the  administra- 
tion of  chloroform,  Avhich  is  of  more  assistance  than  any  change  of 
position  can  possibly  be.  Various  complex  instruments  have  been 
invented  to  facilitate  the  operation,  but  they  are  all  more  or  less  danger- 
ous, and  are  unlikely  to  succeed  when  manual  ])ressure  lias  failed. 

As  soon  as  the  reduction  is  accomplished,  subsequent  descent  of  the 
uterus  should  be  prevented  by  a  large-sized  Hodge's  ])essarv,  and  the 
patient  should  be  ke])t  at  rest  for  some  days,  tlie  state  of  the  bladder 
and  bowels  being  ])articularly  attended  to.  \\' hen  repositiou  has  been 
fairly  effected  a  relapse  is  unlikely  to  occur. 

>-ln  cases  in  which  reduction  is  found  to  be  impossible  our  only 
/resource  is  the  artificial  induction  of  abortion.  Under  such  circum- 
stances this  is  imperatively  called  for.  It  is  best  effected  by  ])unctur- 
ing  the  membranes,  the  discharge  of  the  liquor  amuii  of  itself  lessen- 
ing the  size  of  the  uterus,  and  thus  diminishing  the  pressure  to  -which 
the  neighboring  parts  are  subjected.  After  this,  rej)osition  may  be  pos- 
sible, or  Ave  may  wait  until  the  foetus  is  spontaneously  expelled.  It  is 
not  ahvays  easy  to  reach  the  os  uteri,  although  we  can  generally  do  so 
Avith  a  curved  uterine  sound.  If  we  cannot  j)uncture  the  membranes, 
the  liquor  amnii  may  be  drawn  off  through  the  uterine  walls  by  means 
of  the  aspirator  inserted  through  either  the  rectum  or  vagina.  The 
injurv  to  the  uterine  walls  thus  inflicted  is  not  likely  to  be  hurtful,  and 
the  risk  is  certainly  far  less  than  leaving  the  case  alone.  Naturally,  so 
extreme  a  measure  would  not  be  adopted  until  all  the  simpler  means 
indicated   have  l)eon  tried  and   failed. 

Diseases  coexisting  with  Prep-nancy. — The  ])regnant  woman  is, 
of  cou^e^iaEle^con  tract  thii  yuiliy  diseases  as  in  the  non-pregnant 
state,  and  pregnancy  may  occur  in  M'omen  already  the  subject  of  some 
constitutional  disease.  There  is  no  doubt  yet  much  to  be  learned  as  to 
the  influence  of  coexisting  disease  on  pregnancy.  It  is  certain  that  some 
diseases  are  but  little  modified  by  pregnancy,  and  that  others  are  so  to 
a  considerable  extent,  and  that  the  influence  of  the  disease  on  the  foetus 
varies  much.  The  subject  is  too  extensive  to  be  entered  into  at  any 
length,  but  a  few  words  may  be  said  as  to  some  of  the  more  important 
affections  that  are  likely  to  be  met  with. 

The  eruptive  fevers  have  often  very  serious  consequences,  propor- 
tionate to  the  intensity  of  the  attack.  Of  these  variola  has  the  most 
disastrous  results,  Avhieh  are  related  in  the  writings  of  the  older  authors, 
but  which  are,  fortunately,  rarely  seen  in  these  days  of  vaccination. 
(The  severe  and  confluent  forms  of  the  disease  are  almo.s^  certainly  fatal 
to  both  the  mother  and  child.)   In  the  discrete  form  and  in  modified 


DISEASES  OF  PREGNANCY.  223 

smallpox  after  vaccination  the  patient  generally  has  the  disease  favor-  ) 
ably,  and,  although  abortion  frequently  results,  it  does  not  necessarily^ 
do  so.  " 

If  scarlet  fever  of  an  intense  character  attacks  a  pregnant  woman, 
abortion  is  likely  to  occur  and  the  risks  to  the  mother  are  very  great. 
The  mlTd^LT  cases  run  their  course  without  the  production  of  any  unto- 
ward symptoms.  Should  abortion  occur,  the  well-known  dangerous 
effect  of  this  zymotic  disease  after  delivery  will  gravely  influence  the 
prognosis.  Cazeaux  was  of  opinion  that  pregnant  women  are  not  apt 
to  contract  the  disease ;  while  Montgomery  thought  that  the  ]}oison 
when  absorbed  during  pregnancy  might  remain  latent  until  delivery, 
when  its  characteristic  effects  were  produced. 

yVEeasles,  unless  very  severe,  often  runs  its  course  without  seriously 
affecting  the  mother  or  child.  \  I  have  myself  seen  several  examples  of 
this.  De  Tourcoing,  however,  states  that  out  of  15  cases  the  mother 
aborted  in  7,  these  being  all  very  severe  attacks.  Some  cases  are 
recorded  in  which  the  child  was  born  with  the  rubeolous  eruption 
upon  it. 

The  pregnant  woman  may  be  attacked  with  any  of  the  continued 
fevers,  and  if  they  are  at  all  severe  they  are  apt  to  produce  abortion. 
Out  of  22  cases  of  typhoid,  16  aborted,  and  the  remaining  6,  who  had 
slight  attacks,  went  on  to  term  ;  out  of  63  cases  of  relapsing  fever, 
abortion  or  premature  labor  occurred  in  23.  According  to  Schweden, 
the  main  cause  of  danger  to  the  foetus  in  continued  fevers  is  the  hyper- 
l^yrexia,  especially  when  the  maternal  temperature  reaches  104°  or 
upward.  The  fevers  do  not  appear  to  be  aggravated  as  regards  the 
mother,  and  the  same  observation  has  been  made  by  Cazeaux  with 
regard  to  this  class  of  disease  occurring  after  delivery. 

Pneumonia  seems  to  be  specially  dangerous,  for  of  1 5  cases  collected 
by  Grisolle,'  11  died — a  mortality  immensely  greater  than  that  of  the 
disease  in  general.  The  larger  proportion  also  aborted,  the  children 
being  generally  dead,  and  the  fatal  result  is  probably  due,  as  in  the 
severe  continued  fevers,  to  hyperpyrexia.  The  cause  of  the  maternal 
mortality  does  not  seem  quite  apparent,  since  the  same  danger  does  not 
appear  to  exist  in  severe  bronchitis  or  other  inflammatory  affections. 

Contrary  to  the  usually  received  opinion,  it  appears  certain  that 
pregnancy  has  no  retarding  influence  on  coexisting  phthisis,  nor  does 
the  disease  necessarily  advance  with  greater  rapidity  after  delivery. 
Out  of  27  cases  of  ])hthisis  collected  by  Grisolle,  24  showed  the  first 
symptoms  of  the  disease  after  pregnancy  had  commenced.  Phthisical 
Avomen  are  not  apt  to  conceive — a  fact  which  may  probably  be  explained 
by  the  frequent  coexistence  in  such  cases  of  uterine  disease,  especially 
severe  leucorrhoea.  The  entire  duration  of  the  phthisis  seems  to  be 
shortened,  as  it  averaged  only  nine  and  a  half  months  in  the  27  cases 
collected — a  fact  which  proves  at  least  that  pregnancy  has  no  material 
influence  in  arresting  its  progress.  If  we  consider  the  tax  on  the  vital 
powers  which  pregnancy  naturally  involves,  we  must  admit  that  this 
view  is  more  physiologically  ])robable  than  the  one  generally  received, 
and  apparently  adopted  without  any  due  grounds. 

'  Arch.  gen.  de  Med.,  vol.  xiii.  p.  291. 


224  piiKayAycY. 

Tlu'  I'vil  ofTccts  of  preornaiicy  aixl  paidirition  on  clironic  heart  dis- 
ease have  ol"  late  rercivcd  iiiufli  attention   from   Sj>ieo;eIl)('rj;,  I'^ritnli, 
Peter,  and  other  ^\■riters.     The  subject  has  been  ably  discussed  '  in  a 
series  of  elaborate  papers   bv  Dr  Angus  Maedonald,   which  are  well 
worthy  of  study.     Out   of  28  eases  collected   by  him,  17,  <>v  00  per 
cent.,  proved  iiital.     This,  no  doubt,  is  not  altogether  a  relialjlc  estimate 
of  the  pr(»l)able   risk   of  the  coMiplication  ;  but,  at  any  rate,  \t   shou.>|< 
the  serious  anxiety  which  the  occui'rence  of  pregnancy  in  a  patient  Mif4 
j  Ifering  from  chronic  heart-disease  nuist  cause,  i  Dr.  Maedonald  refers  thqj 
//evils  resulting  from  pregnancy  in  connection  with  cardiac  lesions  to 
'two  causes:  first,  destruction   of   that  ecpiilibriuni   of   the  circulation 
which  has  been  established    l)y  compensatory  arrangements ;  secondly, 
the  occurrence  of  fresh  inflammatory  lesions  upon  the  valves  of  the 
heart  already  diseased. 

The  dangerous  symptoms  do  not  usually  appear  until  after  the  first 
half  of  the  pregnancy  has  passed,  and  the  j>regnaucy  seldom  advances 
to  term.  The  pathological  phenomena  generally  met  with  in  fatal  cases 
are  pulmonary  congestion,  especially  of  the  l^ronchial  mucous  mem- 
brane, and  pulmonary  oedema,  with  occasional  pneumonia  and  })leurisy. 
]Mitral  stenosis  seems  to  be  the  form  of  cardiac  lesion  most  likely  to 
prove  serious,  and  next  to  this  aortic  incompetency.  The  r»l)vious 
deduction  from  these  facts  is  that  heart  disease,  especially  when  asso- 
ciated with  serious  symptoms,  such  as  dyspncca,  palpitation,  and  the 
like,  should  be  considered  a  strong  contraindication  of  marriage.  When 
pregnancy  has  actually  occurred,  all  that  can  be  done  is  to  enjoin  the 
careful  regulation  of  the  life  of  the  patient,  so  as  to  avoid  exposure  to 
cold  and  all  forms  of  severe  exertion. 

The  important  influence  of  syphilis  on  the  ovum  is  fully  considered 
elsewhere.  As  regards  the  mother,  its  effects  are  not  different  from 
those  at  other  times.  It  need  only  therefore  be  said  that  whenever 
indications  of  syphilis  in  a  pregnant  woman  exist,  the  a})proj)rinte 
treatment  should  be  at  once  instituted  and  carried  on  during  her  ges- 
tation, not  only  with  the  view  of  checking  the  progress  of  the  disease, 
but  in  the  hope  of  preventing  or  lessening  the  risk  of  abortion  or  of 
the  birth  of  an  infected  infant.  So  far  from  pregnancy  contraindica- 
ting  mercurial  treatment,  there  rather  is  a  reason  for  insisting  on  it  more 
stronglv.  As  to  the  precise  medication,  it  is  advisable  to  choose  a  form 
that  can  be  exhil)ited  continuously  foi'  a  length  of  time  without  produ- 
cing serious  constitutional  results.  VSmall  doses  of  the  bichloride  of 
i  mercury,  such_aa.QJaCrSixte£nth_of  .ILgrain  thrice  daily^orbf  the  iodide 
jof  mercury,  or  of  the  hydrargyrum  cum_creta  in  wmbination  with 
'reduced  iron,  answer  the  ])nrposc  well;  or  in  the  early  stages  of  preg- 
nancv  the  mercurial  vapor-bath  or  cutaneous  inunction  may  be 
employed. 

Dr.  Weber  of  St.  Petersburg  ^  has  made  some  observations  showing 
the  superiority  of  the  latter  methods,  which  he  found  did  not  interfere 
with  the  course  of  pregnancy  ;  the  contrary  was  the  case  when  the  mer- 
cury was  administered  by  the  mouth,  probably,  as  he  supposes,  from 
disturbance  of  the  digestive  system.     It  must  be  borne  in  mind  that  in 

1  Obst.  Journ.,  vol.  v.,  1877,  p.  217.  »  Allyem.  Med.  Cent.  Zeit.,  Feb.,  1875. 


DISEASES  OF  PREGNANCY.  225 

married  women  it  may  sometimes  be  expedient  to  preserihe  an  anti- 
sypliilitic  course  M'itliout  their  knowledt^e  of  its  nature,  so  tliat  inunc- 
tion is  not  always  feasible. 

The  influence  of  j)regnancy  on  ^pilepsv  chjcs  not  api)ear  to  be  as  uni-* 
form  as  might  perhaps  be  expected.  In  some  cases  the  number  and{ 
intensity  of  the  fits  have  been  lessened,  in  others  the  disease  becomes 
aggravated.  Some  cases  are  even  recorded  in  wliich  epilepsy  api)eared 
for  the  first  time  during  gestation.  On  account  of  the  resemblance' 
between  epilepsy  and  eclampsia  there  is  a  natural  apprehension  that 
a  pregnant  epileptic  may  suffer  from  convulsions  during  delivery. 
Fortunately,  this  is  by  no  means  necessarily  the  case,  and  labor  often 
goes  on  satisfactorily  without  any  attack. 

Certain  diseases  of  the  eye  are  observed  during  pregnancy.  They 
have  been  well  studied  by  l^lr.  Power.^  One  of  the  most  common 
disturbances  of  vision  is  due  to  temporary  impairment  of  accommoda- 
tion, most  generally  in  patients  who  are  naturally  hypermetroj^ic,  and 
is  dependent  on  exhaustion  of  the  neuro-muscular  apparatus.  The 
symptoms  are  chiefly  difficulty  in  reading,  sewing,  or  other  work 
requiring  minute  vision — pain,  black  spots  before  the  eyes,  lachryma- 
tiou,  etc.  Suitable  convex  glasses  may  be  required,  and  with  attention 
to  the  general  health  the  symptoms  may  disappear.  Other  diseases 
more  serious  and  lasting  in  their  results  are  also  met  with.  Mr.  Power 
describes  certain  important  changes  in  the  eye  met  with  in  cases  of  albu- 
minuria. The  optic  disk  is  swollen  and  congested,  and  irregular  hem- 
orrhages and  white  disks  are  seen  in  the  retina.  The  hemorrhages  he 
ascribes  to  actual  rupture  of  the  vessels  ;  the  white  patches  to  a  lesser 
degree  of  distension,  admitting  of  the  escape  of  white  corpuscles  through 
the  vascular  walls.  In  many  of  these  cases  the  vision  was  ultimately 
regained.  Another  form  of  disease  he  describes  is  "  white  atrophy  of 
the  optic  disk,"  probably  following  neuritis,  occurring  in  cases  in  which 
there  had  been  irreat  loss  of  blood. 

Jaundice,  the  result  of  acute  yellow  atrophy  of  the  liver,  is  occa-  \ 
sionally  observed,  and  is  said  to  have  been  sometimes  epidemic,     Inde- ' 
pendently  of  the  grave  risks  to  the  mother,  it  is  most  likely  to  produeej 
abortion  or  the  death  of  the  foetus.     According  to  Davidson,-  it  origi- 
nates in  catarrhal  icterus,   the   excretion   of  the   bile-products  being 
impeded  in  consequence  of  ]">reguancy,  and  their  retention  giving  rise  to 
the  fatal  blood-poisoning  which  accompanies  the  severer  forms  of  the 
disease.     Slight  and  transient  attacks  of  jaundice  may  occur  without 
being   accompanied   by  any  bad  consequences.     Their   production  is 
probably  favored  by  the  mechanical  pressure  of  the  gravid  uterus  on 
the  intestines  and  the  bile-ducts. 

The  occurrence  of  pregnancy  in  a  woman  suffering  from  malignant 
disease  of  the  uterus  is  by  no  means  so  rare  as  might  be  supjiosed,  and 
must  naturally  give  rise  to  much  anxiety  as  to  the  result.  The  obstet- 
rical treatment  of  these  cases  will  be  discussed  elsewhere.  Should  we 
be  aware  of  the  existence  of  the  disease  during  gestation,  the  question 
will  arise  whether  we  should  not  attempt  to  lessen  the  risks  of  delivery 
by  bringing  on  abortion  or  premature  labor.     The  question  is  one  which 

1  Barnes,  Obst.  Med.,  vol.  i.  p.  390.  «  Monat.J.  GeburL,  1S67,  Bd.  xxx.  S.  452, 

15 


226  PREGNANCY. 

is  by  no  means  oasy  to  settle.  AVc  have  to  deal  with  a  disease  wliieh  is 
certain  to  prove  fatal  to  the  mother  l)ef"ore  l(»n^,  and  the  pn^gre.ss  of 
which  is  })r<>i)ably  accelerated  after  labor,  while  the  manipnlations  neces- 
sary to  induce  delivery  may  very  unfavorably  influence  the  diseased 
structures.  Again,  by  such  a  measure  we  necessarily  sacrifice  the  child, 
while  we  are  by  no  means  certain  that  we  materially  lessen  the  danger 
to  the  mother.  The  question  cannot  be  settled  excejit  on  a  considera- 
tion of  each  ])articu]ar  case.  If  we  see  the  patient  early  in  pregnancy, 
by  inducing  abortion  we  may  save  her  the  dangers  of  labor  at  term — 
possibly  of  the  Ctesareau  section — if  the  obstruction  be  great.  Under 
such  circinn stances  the  operation  would  be  justifiable.  If  the  pregnancy 
has  advanced  beyond  the  sixth  or  seventh  month,  unless  the  amount  of 
malignant  deposit  be  very  small  indeed,  it  is  probable  that  the  risks  of 
labor  would  be  as  great  to  the  mother  as  at  term,  and  it  Avould  then  be 
advisable  to  give  her  the  advantage  of  the  few  months'  delay. 

Cases  are  occasionally  met  with  in  Avhich  pregnancy  occurs  in  women 
who  are  suifering  from  ovarian  tumor,  and  their  proj)er  management 
has  g-iven  rise  to  considerable  discussion.  There  can  be  no  doubt  that 
such  cases  are  attended  with  very  dangerous  and  often  fatal  conse- 
quences, for  the  abdomen  cannot  well  accommodate  the  gravid  uterus  and 
the  ovarian  tumor,  both  increasing  simultaneously.  The  result  is  that 
the  tumor  is  subject  to  much  contusion  and  pressure,  which  has  some- 
times led  to  the  rupture  of  the  cyst  and  the  escape  of  its  contents  into 
the  peritoneal  cavity;  at  others,  to  a  low  form  of  inflammation  attended 
with  much  exhaustion,  the  death  of  the  patient  supervening  either  before 
or  shortly  after  delivery.  The  danger  during  delivery  from  the  same 
cause  in  the  cases  which  go  on  to  term  is  also  very  great.  Of  13  cases 
of  delivery  by  the  natural  powers  which  I  collected  in  a  paper  on 
*'  Labor  complicated  with  Ovarian  Tumor,"  ^  far  more  than  one-half 
proved  fatal.  Another  source  of  danger  is  twisting  of  the  pedicle,  and 
consequent  strangulation  of  the  cyst,  of  which  several  instances  are 
recorded.  It  is  obvious,  then,  that  the  risks  are  so  manifold  that  in  » 
every  case  it  is  advisable  to  consider  whether  they  can  be  lessened  by  i 
surgical  treatment.  ' 

/'  The  means  at  our  disposal  are  either  to  induce  labor  prematurely,  to 
(  treat  the  tumor  by  tap])ing,  or  to  j)erform  ovariotomy.  /^The  (juestion 
j  has  been  particularly  discussed  by  Spencer  Wells  in  (his  works  on' 
Ovariotomy,  and  l)y  Barnes  in  his  Obsfdric  Operation.^.  The  Ibrmer 
holds  that  the  proper  course  to  pui-sue  is  to  tap  the  tumor  when  there  is 
any  chance  of  its  being  materially  lessened  in  size  by  that  ]>rocedure,  but 
that  when  it  is  multilocular  or  when  its  contents  are  solid  ovariotouiyl 
should  be  performed  at  as  early  a  period  of  pregnancy  as  possible/ 
Barnes,  on  the  other  hand,  maintains  that  the  safer  course  is  to  imitate 
the  means  by  which  nature  often  meets  this  complication,  and  bring  ou 
premature  labor  without  interfenng  with  the  tumor.  He  thinks  ovari- 
otomy out  of  the  question,  and  that  tajiping  may  be  insufficient  and 
leave  enough  of  the  tumor  to  interfere  seriously  with  labor.  So  far  as 
recorded  cases  go,  they  unquestionably  seem  to  show  that  tajiping  is 
not  more  dangerous  than  at  other  times,  and  that  ovariotomy  may  be 

1  Obst.  Trans.,  1867,  vol.  ix.  p.  69. 


DISEASES  OF  PREGNANCY.  227 

practised  flaring  ]>regiiancy  with  a  fair  amount  of  success.  AVells 
records  10  cases  which  were  surgically  interfered  with.  In  1  tapping 
was  j)erfornied,  and  in  9  ovariotomy  ;  and  of  these  8  recovered,  the 
j)regnancy  going  on  to  term  in  5.  On  tlie  other  hand,  5  cases  were  left 
alone,  and  either  went  to  term  or  spontaneous  premature  labor  super- 
vened ;  and  of  these,  3  died.  The  cases  are  not  sufficiently  numerous 
to  settle  the  question,  but  they  certainly  favor  the  view  taken  by  Wells 
rather  than  that  by  Barnes.  It  is  to  be  observed  that  unless  we  give  up 
all  hope  of  saving  the  child  and  induce  abortion,  the  risk  of  induced 
premature  labor  when  the  pregnancy  is  sufficiently  advanced  to  hope  for 
a  viable  child  woidd  almost  be  as  great  as  that  of  labor  at  term  ;  for  the 
question  of  interference  will  only  have  to  be  considered  with  regard  to 
large  tumors,  which  would  be  nearly  as  much  affected  by  the  pressure 
of  a  o-ravid  uterus  at  seven  or  eio-ht  months  as  bv  one  at  term.  Small 
tumors  generally  escape  attention,  and  are  more  apt  to  be  impacted 
before  the  presenting  part  in  delivery.  The  success  of  ovariotomy 
during  pregnancy  has  certainly  been  great;  and  we  have  to  bear  in 
mind  that  the  woman  must  necessarily  be  subjected  to  the  risk  of  the 
operation  sooner  or  later,  so  that  we  cannot  judge  of  the  case  as  one  in 
which  abortion  terminates  the  risk.  Even  if  the  operation  should  put 
an  end  to  the  pregnancy — and  there  is  at  least  a  fair  chance  that  it  will 
not  do  so — there  is  no  certainty  that  that  would  increase  the  risk  of  the 
operation  to  the  mother,  while  as  regards  the  child  we  should  only  have 
the  same  result  as  if  we  intentionally  produced  abortion.  On  tlTeTN 
whole,  then,  it  seems  that  the  best  chance  to  the  mother,  and  certainly  j 
the  best  to  the  child,  is  to  resort  to  the  apparently  heroic  treatment  | 
recommended  by  Wells.  The  determination  must,  however,  be  to  some 
extent  influenced  by  the  skill  and  experience  of  the  operator.  If  the 
medical  attendant  has  not  gained  that  experience  which  is  so  essential 
for  a  successful  ovariotomist,  the  interests  of  the  mother  would  be  best 
consulted  by  the  induction  of  abortion  at  as  early  a  period  as  possible. 
One  or  other  procedure  is  essential ;  for,  in  spite  of  a  few  cases  in  which 
several  successive  pregnancies  have  occurred  in  women  who  have  had 
ovarian  tumors,  the  risks  are  such  as  not  to  justify  an  expectant  practice. 
Should  rupture  of  the  cyst  occur,  there  can  be  no  doubt  that  ovariotomy 
should  at  once  be  resorted  to,  with  the  view  of  removing  the  lacerated  cyst 
and  its  extravasated  contents. 

Pregnancy  may  occur  in  a  uterus  in  which  there  are  one  or  more 
fibroid  tumors.  During  pregnancy  they  may  lead  to  premature  labor 
or  abortion,  to  peritonitis,  or  they  may  cause  so  much  pain  and  discom-™ 
fort  from  their  size  as  to  rciidci'  interference  imperative.  ir'the5^*are 
situated  low  down  and  in  a  jjosition  likely  to  obstruct  the  passage  of 
the  foetus,  they  may  very  seriously  comjilicate  delivery.  AVhen  thev  are 
situated  in  the  fundus  or  body  of  the  uterus  they  mav  give  rise  to  risk 
from  hemorrhage  or  from  inflammation  of  their  o-svu-  structure.  Inas-| 
much  as  they  are  structurally  similar  to  the  uterine  walls,  they  partakel 
of  the  growth  of  the  uterus  during  pregnancy,  and  frequently  increasej 
remarkably  in  size.  Cazeaux  says :  "  I  have  known  them  in  several 
instances  to  acquire  a  size  in  three  or  four  months  which  they  would 
not  have  done  in  several  years  in  the  non-pregnant  condition."     Con- 


228  PRi'y;\A.\CY. 

vcrsely,  tlicy  sliaro  in  the  iiivdliitioii  (»("  tlic  uterus  after  dclivorv,  and 
often  lessen  <;ivatly  in  size  or  even  entirely  disapjx'ai".  Of"  this  I'act  I 
have  elsewhere  recorded  several  curious  exani])les;'  and  many  other 
instances  of"  the  complete  disappearance  of  oven  large  tumors  have  Iteen 
described  by  authors  whose  accuracy  of  observation  cannot  be  (jues- 
tioued. 

The  treatment  will  vary  with  the  size  and  position  ol"  the  tumoi-,  ami 
every  case  must  be  treated  on  its  own  merits,  since  it  is  not  possible  to 
lay  down  rules  that  will  aj)})ly  to  all  cases  alike.     A  f"nll  report  of"  all 
recent  cases  will  be  found  in  Dr.  John  l*hillii)s'^  recent  j)aper,  which 
shows  how  serious  the  results  often  are.     If  the  position  of  the  tumor 
be  such  as  to  render  it  certain  to  obstruct  delivery,  the  production  of 
early  abortion  is  perhajjs  the  best  course  to  })ursue.     It  is  not  without 
serious  risks,  but  j)rubal)ly  less  than  allowing-  pregnancy  to  proceed  to 
term.     In  several  instances  either  the  removal  of  the  tumor  itself  by 
abdominal  section  (myomotomy)  or  the  removal  of  the  tumor  and  the 
gravid  uterus  (^liillcr's  ablation)  has  been  resorted  to  on  accounl  of  the 
grave  concomitant  symptoms,  aud  with  a  fair  measure  of  success.     If 
the  tumor  is  well  out  of  the  way,  interference  is  not  so  urgently  called 
for.     The  principal  danger  then  is  that  the  tumor  will  impede  the  post- 
partum contraction  of  the  uterus  and  favor  hemorrhage.     Even  if  this 
should  happen,  the  flooding  could  be  controlled  by  the  usual  means, 
especially  by  the  injection  of  the  perchloride  of  iron.     I  have  seen 
several  cases  in  which  delivery  lias  taken  place  under  such  circum- 
stances without  any  untoward  accident.     The  danger  from  inflamma- 
tion and  subsequent  extrusion  of  the  fibroid  masses  would  proi)ably  be 
as  great  after  abortion  or  premature  labor  as  after  delivery  at  term,    ^'i 
seems,  therefore,  to  be  the  proper  rule  to  interfere  when  the  tumors  are  i 
likely  to  impede  delivery,  and  in  other  cases  to  allow  the  pregnancy  to  { 
go  on,  and  be  prepared  to  cope  with  any  complications  as  they  arise,  t 
The  risks  of  pregnancy  should  be  avoided  in  every  case  in  which  uterine  ; 
fibroids  of  any  size  exist,  the  patients  being  advised  to  lead  a  celibate  j 
life. 

1  Obst.  Trans.,  1869,  vol.  x.  p.  102;    1872,  vol.  xiii.  p.  288  ;  1877,  vol.  xix.  p.  101. 
^  "  The  Management  of  Fibro-myomata  complicating  Pregnancy  and  Labor,"  Brit. 
Med.  Journ.,  1888,  vol.  i.  p.  1331. 


PATHOLOGY  OF  THE  DECIDUA  ASD   OVUM.  229 


CHAPTER   IX.- 

PATHOLOGY   OF   THE    DECIDUA   AND   OVUM. 

Patholog-y  of  the  Decidua. — Comparatively  little  is,  unfortunately, 
known  of  the  pathological  changes  Avhich  occur  in  the  mucous  mem- 
brane of  the  uterus  during  pregnancy.  It  is  probable  that  they  are 
of  much  more  consequence  than  is  generally  believed  to  be  the  case,  and 
it  is  certain  that  they  are  a  fi'('(jii('iit  cause  of  abortion. 

'  One  of  the  most  generally  obscrxcd  probably  depends  on  endome- 
tritis antecedent  to  conception.  When  the  impregnated  ovulelreaclied 
the  uterus  it  engrafted  itself  on  the  inflamed  mucous  membrane,  which 

Fig.  88. 


Hypertrophied  Decidua  laid  open,  with  the  ovum  attached  to  its  fundal  portion.     (After 

Duncan.) 

was  in  an  unfit  condition  for  its  reception  and  growth.  (  A  not  uncom- 
mon result  under  such  circumstances  is  the  laceration  of  some  of  the 
decidual  vessels,  extravasation  of  the  blood  between  the  decidua  and  the 


230 


mEnxAXCY 


uterine  walls,  and  consequent  ahurti(jn  at  an  early  stajje  of  pre<rnaney.^ 
As  this  morbid  state  of"  the  uterine  niueous  membrane  is  likely  to  con- 
tinue after  abortion  is  completed,  the  siuiie  history  repeats  itself  on  each 
impregnation,  and  thus  we  may  have  constant  early  miscarriages  pro- 
duced. It  does  not  necessarily  follow,  however,  that  the  pregnancy  is 
immediately  terminated  when  this  state  of  things  is  jtresent.  Some- 
times a  condition  of  hv|iT.'rplasia  of  the  decidua  is  ])rfKhiced,  the  mem- 
brane becomes  much  thickened  and  hypertroj)hied  in  consequence  of 
proliferation  of  its  interstitial  connective  tissue,  and  the  decidual  cells 
are  greatly  increased  in  size  (Fig.  88).  Mn  other  instances  the  internal 
surface  of  the  decidua  becomes  studden  with  rouu^li  polypoid  growths' 
depending  on  proliferation  of  its  intei'Stitial  tissues  Duncan  has  f(jund 
that  the  hypertrophied  decidua  is  always  in  a  state  of  I'atty  degeneration, 
more  advanced  in  some  places  than  in  others.'  The  result  of  these 
alterations  is  frequently  to  produce  dwindling  or  death  of  the  ovum, 
which,  however,  retains  its  connection  with  the  decidua,  until,  after  a 
lapse  of  time,  the  decidua  is  exj)elled  in  the  form  of  a  thick  triangular 
fleshy  substance,  with  the  atro])lii(d  ovum  attached  to  some  part  of  its 
inner  surface.  (  In  other  cases,  in  which  the  hyperplasia  has  advanced  to 
a  less  extent,  the  nutrition  of  the  fo'tus  is  not  interfered  with,  and 
pregnancy  may  continue  to  term,  the  changes  in  the  decidua  being  rec- 
ognizable after  delivery. )  Other  diseases  besides  endometritis  may  give 
rise  to  similar  alterations  in  the  decidua,  one  of  these  being,  as  Virchow 
maintains,  syphijis.  Trhe  converse  condition,  an  im})erfect  development 
of  the  deci(Uia,  especially  of  the  decidua  reflexa,  has  also  been  noted  as 
a  cause  of  abortion.]   The  ovum  will  then  hang  loosely  in  the  uterine 

cavity,  without  the  support  which 
the  growth  of  the  decidua  reflexa 
around  it  ought  to  aflbrd,  and  its 
premature  expulsion  readilv  fol- 
lows (Fig.  89). 

The  peculiar  condition  known 
as  hydrorrhoea  gravidarum  most 
]>rol)ably  depends  on  some  obscure 
morbid  state  of  the  uteriue  mucous 
membrane.  By  it  is  meant  a  dis- 
chaj'ge  of  clear  watery  fluid  at  in- 
tervals during  pregnancy.  It  may 
happen  at  any  period  of  gestation, 
but  is  most  commonly  met  with  in 
the  latier  nioiiths.  It  may  com- 
mence with  a  mere  dribbling,  or 
there  may  be  a  sudden  and  copi- 
ous discharge  of  fluid.  Afterward 
the  watery  fluid,  which  is  genei'ally 
of  a  pale-yellowish  color  and  trans- 
])arent  like  the  liquor  amnii,  may 
continue  to  escape  at  intervals  for  many  weeks,  and  sometimes  in  very 

'  Vircliow'n  Archir.  fur  Path.,  ISOl,  1st  ed. 
*  Researches  in  Obstetrics,  p.  '293. 


Fig.  89. 


Imperfectly  developed  Decidua  Vera,  with  the 
ovum.    (After  Duncan.) 


1 


PATHOLOGY  OF  THE  DECIDUA   AND   OVUM.  231 

•great  abiuidaiu'c,  so  as  to  saturate  the  patient's  clothes.  Very  frequently 
it  is  expelled  in  gushes  and  at  night,  when  the  patient  is  lying  quietly 
in  bed;  its  esea])e  is  then  ])rol)ably  due  to  uterine  (contraction. 

Many  theoricij  have  been  held  as  to  its  cause.  Wy  some  it  is  attrib- 
uted to  the  nipiiirc  of  a  cyst  placed  between  the  ovum  and  the  uterine 
walls:  Baudelocque  referred  it  to  a  transudation  of  the  liquor  amnii 
through  the  membranes,  while  Burgess  and  T)ul)ois  l)elieved  If  to 
de[)end  on  a  laceration  of  the  membranes  at  a  distance  from  the  os 
iiteri ;  (.Mattel  more  recently  has  attributed"  irio  tlie  existence  of  a 
sac  between  the  chorion  and  the  amnion.  \  It  may  be  that  in  some 
instances  a  single  discharge  of  fluid  may  come  from  one  of  the  two  last- 
mentioned  causes.  But  if  it  be  continuous  or  repeated,  another  source 
must  be  sought  for.  Heger^  maintains  that  it  is  the  result  of  abundant 
secretion  from  the  glands  of  the  mucous  iiicnil)rane,  which  are  iifa 
state  of  chronic  inflammation,  the  fluid  accumulating  between  the 
decidua  and  chorion  and  escaping  through  the  os  uteri.  If  this 
occur,  the  decidua  is  probably  in  an  hypertro^ihied  and  otherM'ise 
morbid  state.  (Hydrorrha?a  is  chiefly  of  interest  from  the  error  of 
dia^osis  it  is  likely  to  give  rise  to,'^  for  on  being  summoned  to  a 
case  in  which  watery  discharge  has  occurred  for  the  first  time,  we 
are  naturally  apt  to  sup])Ose  that  the  membranes  have  ruptured  and 
that  labor  is  imminent.  Nor  is  there  any  very  certain  means  of  decid- 
ing if  this  be  so.  In  hydrorrha?a  we  find  that  pains  are  absent,  the  os 
uteri  unopened,  and  ballottement  may  be  made  out.  Even  if  the  mem- 
branes be  ruptured  there  will  be  no  indication  for  interference  unless 
labor  has  actually  commenced ;  and  the  repetition  of  the  discharge  and 
the  continuance  of  the  pregnancy  will  soon  clear  up  the  diagnosis. 
Hydrorrhoea,  although  apt  to  alarm  the  patient,  need  not  give  rise 
to  any  anxiety.  The  pregnancy  generally  ]>r(igrcsses  favorably  to 
the  full  period,  although  in  exceptional  "cases  jnomature  labor  may 
supervene.  No  treatment  is  necessary,  nor  is  there  any  that  could 
have  the  least  effect  in  controlling  the  discharge. 

Patholog"y  of  the  Chorion. — The  only  important  disease  of  the 
chorion  with  which  we  are  acquainted  is  the  well-known  condition 
which  is  variously  described  as  uterine  hydatids,  cystic  disease  pj.  the 
ovum,  hydatid  if orm  degeneration  of  the  chorion,  or  vesicular  mole.  The 
name  of  uterine  hydatids  was  long  given  to  it  on  the  supposition  that 
the  grape-like  vesicles  which  characterize  the  disease  were  true  hydatids^ 
similar  to  those  which  develop  in  the  liver  and  other  structures.  This 
idea  has  long  been  exploded,  and  it  is  now  known  as  a  certainty  that 
the  disease  originates  in  the  villi  of  the  chorion.  The  precise  mode  and 
the  causes  of  its  production  are,  however,  not  yet  satisfactorily  settled. 
The  disease  is  characterized  by  the  existence  in  the  cavity  of  the  uterus 
of  a  large  number  of  translucent  vesicles,  containing  a  clear  limpid 
fluid  which  has  been  found  on  analysis  to  bear  close  resemblance  to  tlie 
li(pK)r  amnii.  These  small  bladder-like  bodies,  which  vary  in  size 
from  that  of  a  millet-seed  to  an  acorn,  are  often  described  as  resembling 
a  bunch  of  grapes  or  currants.  On  more  minute  examination  they  are 
found  not  to  be  each  attached  to  independent  pedicles,  as  is  the  case  in 
'  Monat.  f.  GeburL,  1863,  Bd.  xxii.  S.  429. 


O'lO 


PREOXANCY. 


a  buucli  of  ;j;rai)(-'s,  l)nt  some   oi"  tlu'iii  «5ro\v  Iroiu    other    vt'sicles,  while 

other.s  liavo  distinct  pedicles  attached  to  the 
chorion,  the  jx'dicles  themselves  sometimes 
bein<!;  distended  Ijv  Hnid  (FifJ^.  UO).  Th's 
pecniiar  arrant^enuait  of"  the  \'esicles  is  ex- 
plained by  their  mode  of  growth. 

Causes. — There  Ijas  been  considerable 

discussion  as  to  the  etiolocry  of  this  disease. 

(By  some  it  is  supposed  always  to  follow 

death  of  the  fa-tus ;  and,  the  whole  devel- 

<i])mental   energy  being  expended  on    the 

(  horion,  which  retains  its  attachment  to  the 

decidua,  the  result  is  its  abnormal  growth 

and  cystic  degeneration.!    This  is  the  view 

maintained  by  Gier.se  and  Graily  Hewitt, 

and   it  is  favored   by  the   undoubted   fact 

/^^ k-^W^t ^iP^^'v     ^      that  in  almo.st  all   cases  the  fuetus  has  en- 

S^kW^!^Wf\%^i^d^ki(       tirely  disappeared,  and   by  the  occasional 

occurrence  of  cases  of  twin  conceptions  in 
which  one  chorion  has  degenerated,  the 
other  remaining  healthy  until  term.  (On 
the  other  hand,  it  is  maintained  that  the 
starting-point  is  connected  with  the  n)at(;r- 
nal  organism.  Yirchow  thinks  it  origi- 
Hydntidiform  Degeneration  of  the  nates  iu  a  morbid  State  of  tlie  dccidua, 
Chorion.  Avliile   Others   have  attributed  it  to   some 

blood-dy.scrasia  on  the  part  of  the  mother, 
such  as  i^yii^  There  are  many  rea.sons  for  believing  that  causes  of 
this  nature  may  originate  the  aifection.  Thus,  it  is  often  found  to  occur 
more  than  once  in  the  same  person,  and  alterations  of  a  similar  kind, 
although  limited  in  extent,  are  not  unfrequently  found  in  connection 
^vith  the  placenta  and  membranes  of  living  children.  On  this  theory 
the  (jeatli  of  the  f(etus  is  secondary,  the  consequence  of  impaired  nutri- 
tion from  the  morbid  state  of  the  chorion.  The  ])robability  is  that  both 
views  may  be  right,  the  disease  sometimes  following  the  death  of  thq 
embryo,  and  at  others  being  the  re.sult  of  obscure  maternal  caases. 

Pathology.— IrTlie  degeneration  of  the  chorion  villi  generally  com- 
f  mences  at  an  early  period  of  pi-egnancy,  before  the  ])lacenta  has  com- 
menced to  form.  In  that  case  the  entire  .superficies  ol'  the  chorion 
becomes  affectod.j  The  di.scase,  however,  may  not  Ix'gin  until  after  the 
greater  part  of  the  chorion  villi  have  atrophied,  and  then  it  is  limited 
to  the  placenta)  (The  epithelium  of  the  villi  ap])ears  to  bethejiart  first 
affected,  and  the  whole  interior  of  thedi.seased  villus  becomes  filled  with 
cells.  The  connective  tissue  of  the  villus  undergoes  a  remarkable  pro- 
liferation, and  collects  in  mas-ses  at  individual  spots,  the  remainder  of 
the  villus  being  unalfected.  ]\y  the  growth  ofthe.se  elements  the  villus 
becomes  distended,  tuid  many  of  the  cells  litjuefy,  the  intercellular  iluid 
thus  produced  widely  .separating  the  connective  ti.ssue,  so  as  to  form  a 
network  in  the  interior  of  the  villus.'     Thus  are  formed  the  peculiar 

'  Braxton  Hicks,  Guy's  Hospital  Reports,  vol.  ii.  3d  series,  p.  380. 


PATHOLOGY  OF  THE  DECIDUA  AND   OVUM.  233 

gnij)e-likc  bodies  which  characterize  the  disease.  When  once  the  dcgcii- 
eration  has  commenced  the  diseased  tissue  has  a  remarkable  j)ower  of 
increase,  so  that  it  sometimes  forms  a  mass  as  large  as  a  child's  head  and 
several  ])onnds  in   M-eight. 

'The  uutrition  of  the  altered  chorion  is  maintained  l)y  its  coimecti(mi 
with  the  decidua,Mvhich  is  also  generally  diseased  and  hypertro])iiicdi 
Sometimes  the  adhesion  of  the  mass  to  the  uterine  walls  is  very  tirm, 
and  may  interfere  with  its  expulsion  ;  while  in  a  few  rare  cases  it  has 
been  found  that  the  villi  have  forced  their  way  into  tiie  substance  of  the 
uterus,  chiefly  through  the  uterine  sinuses,  and  thus  caused  atrophy  and 
thinning  of  its  muscular  structure.  Cases  of  this  kind  are  related  by 
Volkmann,  Waldeyer/  and  Barnes,  and  it  is  obvious  that  the  intimate 
adhesion  thus  affected  must  seriously  add  to  the  gravity  of  the  prog- 
nosis. 

(Taking  this  view  of  the  etiology  of  this  disease,  it  is  obvious  that  it\ 
is' essentially  connected  with  pregnancy,  and  that  there  would  be  no 
vajjd  ground  for  maintaining,  as  has  sometimes  been  done,  that  it  may 
occur  independently  of  conception.^'  It  is  just  possible,  however,  that 
true  entozoa  may  form  in  the  substance  of  the  uterus,  which,  being 
expelled  per  vaqlnam,  might  be  taken  for  the  results  of  cystic  disease, 
and  thus  give  rise  to  groundless  suspicions  as  to  the  patient's  chastity. 

Hewitt  has  related  one  case  in  which  true  hydatids,  originally  formed 
in  the  liver,  had  extended  to  the  peritoneum,  and  were  about  to  burst 
through  the  vagina  at  the  time  of  death.  This  occurred  in  an  unmar- 
ried woman.  One  or  two  other  examples  of  true  hydatids  forming  in 
the  substance  of  the  uterus  are  also  recorded.  A  very  interesting  case 
is  also  related  by  Hewitt,^  in  which  undoubted  acephalocysts  were 
expelled  from  the  uterus  of  a  patient  who  ultimately  recovered.  A 
careful  examination  of  the  cyst  and  its  contents  would  show  their  true 
nature,  as  the  echinococci  heads  with  their  characteristic  booklets  would 
be  discoverable  by  the  microscope. 

It  is  also  possible  that  unfounded  suspicions  might  arise  from  the 
fact  of  a  patient  expelling  a  mass  of  hydatids  long  after  impregnation. 
In  the  case  of  a  wddow  or  woman  living  apart  from  her  husband  serious 
mistakes  might  thus  be  made.  This  has  been  especially  pointed  out  by 
McClintock,^  who  says :  "  Hydatids  may  be  retained  in  utero  for  many  '■ 
mouths  or  years,  or  a  portion  only  may  be  expelled,  and  the  residue 
may  throw  out  a  fresh  crop  of  vesicles,  to  be  discharged  on  a  future 
occasion." 

Symptoms  and  Progress. — The  symptoms  of  cystic  disease  of  the 
ovum  are  by  no  means  well  marked.  At  first  there  is  nothing  to  point  to  the 
existenceof  any  morbid  condition,  but  as  pregnancy  advances  its  ordinary 
course  is  interfered  with.  /There  is  more  generaL .disturbance  of  the 
healtli  than  there  ought  to  be,  and  the  reflex  irritations,  such  as  vomit- 
nig,  may  be  unusually  developed. >  The  first  physical  sign  remarked  is 
rapid  increase_of  the  uterine  tumor,  which  soon  does  not  correspond  in 
size  to  the  supposed  period  of  pregnancv. .  Thus  at  the  tliiiil  mouth 
the  uterus  may  be  found  to  reach  up  to  or  beyond  the  umbilicus.    About 

'  Virchow's  Archiv,  vol.  xliv.  p.  86.  ^  06s/.  Trans.,  1871,  vol.  xii.  p.  237. 

^  McClintock's  Diseases  of  Women,  p.  398. 


234  PREGNANCY. 

this  time  there  generally  are  more  or  less  profuse  watery  and  san^-Miiiic- 
ous  disehartres.  which  have  heen  deserihed  as  reseiiii)liii<''  ciirraiit-iiiicc. 
jThey  no  doiri)t  depend  on  the  l)r('akin<>:  down  and  cxjjulsion  of  the 
\cysts,  caiisetl  by  })ainles8  uterine  contractions.  They  are  soniotiiucs 
excessive  in  amount,  recur  wMth  threat  lVe(iueney,  and  often  reduce  the 
patient  extremely.  Portions  of  cysts  may  now  generally  be  found 
minoled  with  the  discharge,  and  sometimes  large  masses  of  them  are 
expelled  from  time  to  time,  ijndeed,  the  discovery  of  portions  of  cvsts 
is  the  only  certain  diagnostic  sign."^  Vaginal  examination,  bcfoi-c  the  os 
has  dilated,  will  give  no  information  except  the  absence  of  ballottement. 
An  unusual  hardness  or  density  of  the  uterus — described  by  Lcishman, 
who  attributes  much  importance  to  it,  as  "a  peculiar  doughy,  boggy 
feeling" — has  been  pointed  out  by  several  writers.  The  contour  of  tlie 
uterine  tumor,  moreover,  is  often  irregular.  In  addition,  we  of  course 
fail  to  discover  the  usual  auscultatory  sig-ns  of  prep^nancv.  All  this 
may  aid  in  diagnosis,  but  nothing  except  the  presence  of  cysts  in  the 
watery  bloody  discharge  will  enable  us  to  pronounce  with  certainty  as 
to  the  nature  of  the  disease. 

Treatment. — As  soon  as  the  diagnosis  is  established  the  indications 
for  treatment  are  obvious.  The  sooner  the  uterus  is  cloarod  of  its  con- 
tents the  better.  Ergot  may  be  given  with  acKantagc  to  favor  uterine 
contraction  and  the  expulsion  of  the  diseased  ovum.  Should  this  fail, 
more  especially  if  the  hemorrhage  be  great,  the  fingers  or  the  whole 
handjnuist  be^introduced  into  the  uterus  and  as  much  as  jiossible  of  the 
mass  removed.  As  the  os  is  likely  to  be  closed,  its  preliminary  dilata- 
tion by  sponge  or  laminaria  tents,  or  by  a  Barnes'  bag  if  it  be  already 
opened  to  some  extent,  will  in  most  cases  be  required.  If  chloroform 
be  theu  administered,  the  remaining  steps  of  the  operation  will  be  easy. 
On  account  of  the  occasional  firm  adhesions  of  the  cystic  mass  to  the 
uterus,  too  energetic  attempts  at  complete  separation  should  be 
avoided.  Any  severe  hemorrhage  after  the  operation  can  be  controlled 
by  swabbing  out  the  uterine  cavity  with  the  jierchloride-(»f-irou  solu- 
tion. 

Under  the  name  of  myxoma  flbrosum  (Fig.  91)  a  more  rare  degen- 
eration of  the  chorion  has  been  described  by  Yirchow  and  Hilde- 
brandt,^  characterized  not  by  vesicular  but  fibroid  degeneration  of 
the  connective  tissue  of  the  chorion,  ^t  results  in  the  enlargement  of 
the  chorionic  villi  by  fibrous  hypertrophy,  forming  distinct  tumors  in  the 
placental  structure,  and  is  more  frequently  met  with  in  the  later  than  the 
earlier  ]ieriods  of  pregiuuuy.  It  does  not,  therefore,  necessarily  lead  to 
the  death  of  the  child.^ 

Pathology  of  the  Placenta. — The  pathology  of  the  placenta  has  of 
late  years  attracted  nuich  attention,  and  it  has  an  important  practical 
bearing  in  consequence  of  its  effect  on  the  child. 

Placentic  vary  considerably  in  shape.  They  may  be  crescentic  or 
spread  over  a  considerabl(~surface  in  oofisequence  of  the  chorion  villi 
entering  into  communication  with  a  larger  portion  of  the  decidua  than 
usual  {placenta  mcmbranacea).     Such  forms,  however,  are  merely  of 

^Monal.  /.  Geburf.,  May,  1865. 

^  I'riestlfv,  Tlic  Patholvyy  uf  Intra-uterinc  Death,  p.  156. 


PATHOLOGY  OF  THE  DECWUA   AND   OVUM. 


235 


scientific  interest.     The  only  anomaly  of  shape  of  any  practical  import- 
ance is  the  formation  of  what  have  been  called  placenta  s uccen t urice. 
/These  consist  of  one  or  more  separate  masses  of  placental  tissue,  pro- 
Iduced  by  the  development  of  isolated  patches  of  chorion  villi.     Hohl 
believes  that  they  always  form  exactly  at  the  junction  of  the  anterior  j 


Fjg,  9!. 


Myxoma  Fibrosum  of  the  Placenta.    (After  Storch 


and  posterior  walls  of  the  uterus,  which  in  early  pregnancy  is  a  mere 
line.  As  the  uterus  expands  the  portions  of  placenta  on  each  side  of 
this  become  separated  from  each  other.  (They  are  only  of  consequence 
from  the  possibility  of  their  remaining '  unnoticed  in  the  uterus  after 
delivery  and  giving  rise  to  secondary  post-partum  hemorrhage.\  The 
rare  form  of  double  placenta  M'ith  a  single  cord  figured  in  the  accom- 
panying woodcut  (Fig.  92)  was  probably  formed  in  this  way,  and  the 
supplementary  portion  in  such  a  case  might  readily  escape  notice. 

The  placenta  may  also  vary  in  dimensions.  (Sometimes  it  is  of  ex- 
cessive size,  generally  when  tlie  child  is  unusually  big,  but  not 
unfrequently  in  connection  with  hydramnios,  the  child  being  dead 
and  shrivelled.  In  other  cases  it  is  remarkably  small,  or  at  least 
appears  to  be  so.  If  the  child  be  healthy,  this  is  probably  of  no 
pathological  importance,  as  its  smallness  may  be  more  apparent  than 
real,  depending  on  its  vessels  not  being  distended  with  blood.  A^^hen 
true_atrophy  of  the  placenta  exists,  the  vitality  of  the  foetus  may  be 
seriously  interfered  with.  This  condition  may  depend  either  on  a 
diseased  state  of  the  chorion  villi  or  of  the  decidua  in  which  they 
are  implanted.^  The  latter  is  the  more  common  of  the  two;  and  it 
generally  consists  in  hyperplasia  of  the  connective  tissue  of  the  decidua, 

•  Whittaker,  Amer.  Jnunt.  of  Obstd.,  1870-71,  vol.  iii.  p.  229. 


•J36 


pnECX.iycY. 


which  ]>r(^'<os  on  tlie  villi  and  vcs-^c'ls  and  <^ivc's  rhe  to  frenonil  or  local 
ati'ophy.)^  The  (•lian<:;e  is  .similar  in  its  nature  to  that  ohservctl  in 
cirrhosis  of  the  liver  and  certain  forms  ol'  JJrigiit's  <lisease.  It  ha.s 
heen  specially  studie<l  by  Hej^er  and  Miiier/  who  describe  it  as  bej^in- 
ninti:  with  a  development  ot"  the  elont^atecl  fusiform  cells  of  the  deeidua, 
accompanied  by  an  increase  of  the  intercellular  p;ranular  material. 
Eventually  the  cells  undergo  fatty  degeneration  and  the  whole  struc- 

Fio.  92. 


Double  I'lacenta,  with  single  cord. 


ture  becomes  fibroid.  (This  has  generally  been  ascribed  to  inflamma- 
tory changes,  and  under  the  name  of  j//nc<nfifis-  has  been  descrii)ed  by 
many  authors,  and  has  been  considered  to  be  a  common  disease.  To  it 
are  attributed  many  of  the  iiiorbid  alterations  which  are  commonly 
observed  in  placentae,  such  as  hepajjzations,  circumscribed  purulent 
deposits,  and  adhesions  to  the  uterine  walls.  Many  modern  path- 
ologists have  doubted  whether  these  changes  are  in  any  projier  sense 
inflammatory.  Whittaker  ol)serves  on  this  ]>oint:  "The  disj>osition  to 
reject  placentitis  altogether  increases  in  modern  times.  Indeed,  it  is  im- 
possible to  conceive  of  inflammation  on  the  modern  theory  (Cohnheim) 
of  that  process,  since  there  are  no  capillaries,  in  the  maternal  portion  at 
least,  through  whose  walls  a  'migration'  might  occur,  and  there  are  no 
nerves  to  regulate  the  contractility  of  the  vessel-walls  in  the  entire 
structure."  Robin  thus  explains  the  various  ])athological  changes 
above  alluded  to:    "What  has  been  taken   for  inflammation  of  the 

'  Virchow's  Archir,  1871. 


PATHOLOGY  OF  THE  DECIDUA  AND   OVUM. 


237 


placeuta  is  nothing  else  than  a  condition  of  transformation  of  Ijlood- 
clots  at  various  periods.  AVhat  hits  been  regarded  as  pus  is  only  fibrin 
in  the  course  of  disorganization,  and  in  those  cases  where  true  pus  has 
been  found  the  pus  did  not  come  from  the  placenta,  but  from  an  inflam- 
mation of  the  tissue  of  the  uterine  vessels  and  an  accidental  deposition 
in  the  tissue  of  the  placenta."  The  extravasations  of  blood  here 
alluded  to  are  of  very  common  occurrence,  and  they  are  found  in  all 
parts  of  the  organ — in  its  substance,  on  its  decidual  surface,  or  imme- 
diately below  the  amnion,  where  they  serve  as  points  of  origin  for  the 
cysts  that  are  there  often  observed.  The  fibrin  thus  deposited  under- 
goes retrograde  metamorphosis  as  in  other  parts  of  the  body;  it  becomes 
decolorized,  undergoes  fatty  degeneration,  or  becomes  changed  into  cal- 
careous masses;  and  in  this  w^ay,  it  is  supposed,  may  be  explained 
the  various  pathological  changes  which  are  so  commonly  observed. 
The  amount  of  retrograde  metamorphosis  and  the  precise  appearance 
presented  will,  of  course,  depend  on  the  time  that  has  elapsed  since  the 
blood  extravasations  took  place. 

Patty  deg-eneration   of  the  placenta,   and  its    influence  on    the 
nutrition  of  the  foetus,  have  been  specially  studied  in  England  by 

Fig.  93. 


Fatty  Degeneration  of  the  Placenta. 


Ba 

mon 


rues  and  Druitt.  (Yellowish  masses  of  varying  sizes  are  very  com-i 

>nly  met  wdth  in  placentae,  and  these  are  found  to  consist,  in  great! 

part,  of  molecular  fat,  mixed  with  a  fine  network  of  fibrous  tissu^ 

(Thetruefatty  degeneration,  however,  specially  affects  the  chorion  villi  ] 

(Fig.  93).     On  microscopic  examination  they  are  found  to  be  altered 


238 


rnj'jGWAscy 


and  inissliapt'ii  in  tlieir  contour  and  to  In-  loaded  with  fine  granular  fiit- 
^rluljulcs.  Siniiiur  <liaii^<s  are  obsei'ved  in  tlio  cells  of  tlie  decidua. 
(Tlie  inlluence  on  the  lu'tiis  will  of'coui-se  depend  on  theextont  to  which 
the  I'nnctions  of  the  villi  are  interfered  with. A  The  probable  cause  of 
I  this  degeneration  is  no  doubt  some  obscure  alteration  injhe  nutrhion  of 
the  tissue  depend  ing  on  the  state  of  the  mothers  health.  The  proba- 
bility is  that  generally  the  fatty  degeneration  is  njjt  a  j)rimitive  chjyige, 
but  a  stage  of  some  other  niori^id  condition  which  precedes  or  is  asso- 
ciated with  it.  Barnes  believes  that  sy|)liilis  has  much  influence  in  its 
production.  Druitt  has  pointed  out  that  some  amount  of  fatty  degen- 
eration is  always  present  in  a  mature  placenta,  and  is  probably  connected 
with  the  physiological  separation  of  the  organ  ;  and  Goodell  has  more 
recently  suggested  that  an  unusual  amount  of  this  change  may  Ije  merely 
an  anticipation  of  the  natural  termination  of  the  life  of  the  ])Iacenta.' 

Other  morbid  states  of  the  placenta,  of  greater  rarity,  are  occasionally 
met  with,  as  an  oedematous  infiltration  of  its  tissue — always  occurring, 
according  to  Lange,  in  cases  of  hydramnios — pigmentaiy  amd^akgireous 
deposits,  and  tumors  of  various  kinds;  but  these  require  only  a  passing 
mention. 

Patholog-y  of  the  Umbilical  Cord. — The  umbilical  cord  may  be  of 
excessive  length,  vaiying  fi-om  18  Jo  20  inches,  which  is  its  average 
measuremeut,  up  to  50  or  60  inclies,  and  a  case  is  recorded  in  which  it 
even  reached  the  extraordinarv  leng-th  of  9  feet.  If  unusuallv  long  it 
may  be  twisted  round  the  limbs  or  neck  of  the  child,  and  the  latter 
position  may,  in  exceptional  instances,  prove  injurious  during  labor. 
Some  authors  refer  eases  of  spontaneous  amputation  of  feet  a  1  limbs  in 
M^ero  to  constrictions  by  the  umbilical  cord,  l)ut  this  accident  is  more 

probably  produced  by  filamentous  adnexa 
of  the  amnion.  Knots  in  the  cord  are  not 
uncommon,  and  they  result  from  the  frotus 
in  its  movements  passing  through  a  loop 
of  the  cord  (Fig.  94).  If  there  is  an  aver- 
age amount  of  \\'harton's  jelly  in  the  cord, 
the  vessels  are  protected  from  jnx'ssure  and 
no  bad  effects  follow.  Gery  in  a  recent 
paper  on  the  subject^  attempts  to  show  tiiat 
such  knots  arc  more  important  than  is  gen- 
erally believed,  and  relates  two  cases  in 
which  he  i)elieves  them  to  have  caused  the 
death  of  the  foetus. 

^  Extreine  torsion  of  the  cord,  an  exag- 
geration of  the  spiral  twists  generally 
observed,  may  prove  injin-ious,  and  even 
fatal,  to  the  child  by  obstructing  the  cir- 
culation in  the  vessels.  Spaeth  mentions 
three  cases  in  which  this  caused  the  death 
of  the  f(ftus,  the  cord  being  twisted  until 
it  was  reduced  to  the  thickness  of  a  thread. 
[I  have  in  my  possession  a  very  remark- 

^  Am.  Journ.  Obstel.,  1869-70,  vol.  ii.  p.  535.  '  L'  Union  medimle,  Oct.,  1876. 


Fig.  94. 


Knots  of  th^  Umbilical  Cord. 


I 


PATlIOLOilY  OF  THE  DECIDUA   AND   OVUM.  239 

able  funis  which  I  exhibited  before  the  Patliologieal  Society  of  Phila- 
delphia thirty  years  ago,  the  day  after  its  removal  from  a  primij)ara, 
who  <^ave  birth  to  a  stroiiu;  male  fetus.  The  entire  cord  from  umbili(,-us 
to  ])lacenta  was  twisted  in  the  form  of  a  helix,  the  turns  numberin;^ 
between  thirty  and  forty,  very  regularly  arranged,  and  constituting  a 
cylinder  of  about  |  of  an  inch  in  diameter — long  enough  to  reach  from 
the  umbilicus  to  the  shoulder  of  the  child,  around  the  back  of  the  neck, 
down  over  its  abdomen,  and  to  the  placenta,  which  was  firmly  attached 
within  the  uterus  after  the  foetus  was  expelled.  The  cord,  irrespective 
of  its  twist,  was  of  full  average  length,  and  did  not  appear  to  offer  any 
appreciable  obstacle  to  the  flow  of  blood. — Ed.] 

Ajflomalies  in  the  distribution  of  the  vessels  of  the  cord  are  of  common 
occurrence.'  The  cord  may  be  attached  to  the  edge  instead  of  to  the 
centre  of  tlie  placenta  (battledore  placenta).  It  may  break  up  into  its 
component  parts  before  reaching  the  placenta,  the  vessels  running 
through  the  membranes ;  and  if,  in  such  a  case,  traction  on  the  cord  be 
made,  the  separate  vessels  may  lacerate  and  the  cord  become  detached. 
There  may  be  two  veins  and  one  artery,  or  only  one  vein  and  one 
iartery,  or  there  may  be  two  separate  cords  to  one  placenta.  These 
and  other  anomalies  that  might  be  mentioned  are  of  little  practical 
importance. 

Patholog-y  of  the  Amnion. — The  principal  pathological  condition 
of  the  amnion  with  which  we  are  acquainted  is  that  which  is  associated 
with  excessive  secretion  of  liquor  amnii,  and  is  generally  known  under 
the  name  of  hydramniosi  which  term  Kidd  ^  limits  to  cases  in  which 
more  than  two  quarts  of  amniotic  fluid  exist.  Its  precise  cause  is  still  a 
matter  of  doubt.  By  some  it  is  referred  to  inflammation  of  the  amnion 
itself;  at  other  times  it  is  apparently  connected  with  some  morbid  state 
of  the  decidua,  which  may  be  found  diseased  and  hypertrophied.  The 
foetus  is  very  often  dead  and  shrivelled  and  the  placenta  enlarged  and 
oedematous.  (it  does  not  necessarily  follow,  however,  that  hydramnios 
causes  the  death  of  the  child)  Out  of  33  cases  McClintock  found  that 
9  children  were  born  dead;^  and  of  the  24  born  alive,  ]0  died  within 
a  few  hours ;  the  remainder  survived.  vThere  does  not  appear  to  be  any 
marked  relation  between  the  state  of  the  mother's  health  and  the  occur- 
rence of  this  disease ;)  and  it  is  certainly  not  necessarily  present  when 
the  mother  is  suffering  from  dropsical  effusions  in  other  parts  of  the 
body.  \The  theory  that  the  disease  is  of  jjurely  local  origin  is  favored 
by  the  fact  that  when  hydramnios  occurs  in  twin  pregnancy,  one  ovum 
only  is  generally  affected.;  Its  effects,  as  regards  the  mother,  are  chiefly 
mechanical.  It  rarely  begins  to  show  itself  before  the  fifth  or  sixth 
month  of  pregnancy,  but  when  once  it  has  commenced  it  rapidly  pro- 
duces a  feeling  of  discomfort  and  enlargement  altogether  beyond  that 
which  should  exist  at  the  period  of  pregnancy  which  has  been  reached. 
In  advanced  stages  the  distress  ])roduced  is  often  very  great,  the  enlarged 
uterus  pressing  upon  the  diajihragm  and  producing  nuich  embarrassment 
of  respiration.    Premature  expulsion  of  the  foetus  very  often  supervenes. 

'  "  On  the  Diagnosis  of  Dropsy  of  the  Amnion,"  Proceedings  of  the  Obstetrical  Society 
of  Dublin,  May  11,  ISTS. 
'^  Diseases  of  Wo77ien,  p.  383. 


240  rRECiSA  ^X'Y. 

Four  (lilt  of  McC'lintock's  patients  died  after  lahor,  sliowin^  that  the 
maternal  mortality  is  high — a  result  whieii  he  rei'ers  to  the  dehilitated 
state  of  the  women  who  were  the  subjects  of  the  disease. 

\^I'hj<lr(nnn'ios  is  a  true  eystie  dropsy  of  the  amniotic  sac,  and,  although 
due  to  different  causes, ds  in  tiie  worst  cases  the  result  of  ol)struetion  in 
the  })hieento-l(etal  circuit  of  blood-vessels,  and  mainly  in  the  liver  or 
heart  of  the  fcetiis. ,  The  amnion  lias  the  anatomical  fVatures  of  a 
secreting  membrane,  and  is  (•a])able  of  endosmosis  and  exosmosis,  the 
latter  of  which  is  notably  exhibited  in  the  removal  of  liquor  aninii  after 
fo'tal  death  in  an  ectopic  pregnancy.  A\'hen  from  any  cau.se  the  circu- 
lation of  blood  is  impeded  in  the  foetus,  and  the  placenta  still  keeps  up 
its  functional  activity,  the  disparity  Ijctweeu  placental  supply  and  tVetal 
requirement  will  produce  a  dropsical  effusion  as  the  result  of  the 
mechanical  obstruction  ;  hence  the  large  proportion  of  deaths  in  the  foe- 
tus in  ca.ses  of  hydramnios. — Ed.] 

Diagnosis. — The  diagnosis  is  not,  as  a  rule,  difficult.  It  has  to  be 
distinguished  from  ascitic  distension  of  the  aljdomcn,  from  enlargement 
of  the  uterus  from  t\vin  pregnancy,  and  from  ovarian  tumor  or  preg- 
nancy complicated  with  ovarian  tumoi^  The  first  wIirT)e  recognized  by 
the  superficial  position  of  flie  fluid;  the  difficulty  of  feeling  the  contour 
of  the  uterus,  which  is  obscured  by  the  surrounding  fluid,  and  the  results 
of  percussion,  which  show  that  the  fluid  is  free  in  the  peritoneal  cavity ; 
and  by  the  coexistence  of  dropsical  effusions  in  other  parts  of  the  body. 
The  second  may  be  difficult,  and  even  impossible,  to  diagnose  from  it ; 
generally,  however,  in  hydramnios  the  uterine  tumor  is  more  distinctly 
tense  or  fluctuating,  the  foetal  limbs  cannot  be  felt  on  palpation,  and  the 
lower  segment  of  the  uterus,  as  felt  pervagiinam,  is  unusually  distended, 
the  presenting  part  not  being  appreciable.  Ovarian  tumors  alone  or 
complicating  pregnancy  may  also  be  difficult  to  distinguish  from  dropsy 
of  the  amnion.  The  general  history  of  the  case  and  the  jircsence  or 
absence  of  signs  of  pregnancy  may  enable  us  to  arrive  at  a  diagnosis ; 
and  Kidd  points  out  that  the  position  of  the  uterus,  Avhether  gravid  or 
not,  is  usually  low  down  in  the  pelvis  in  ovarian  dropsy,  Avhile  in 
dropsy  of  the  amnion  it  is  drawn  high  up  and  reached  with  difficulty 
on   vaginal  examination. 

During  labor  an  excessive  amount  of  liquor  amnii  is  often  a  cause  of 
deficient  uterine  action  and  delay,  the  pains  being  feeble  and  ineffective. 
This,  of  course,  tells  chiefly  in  the  first  stage,  Avhich  is  often  much  ]n-o- 
longed,  unless  the  membranes  are  punctured  early  and  the  superabun- 
dant fluid  allo^yed  to  escape. 

Treatraent.^«-Xo  treatment  is  known  to  have  any  effect  on  the  dis- 
ease. J  If  the  discomfort  and  distension  are  very  great,  it  may  be  al)so- 
liitely  necessary  to  ])uncture  the  membranes  and  allow  the  water  to 
escape.  This  inevitably  brings  on  labor.  If  the  jiregnaiKy  l)e  not 
sufficiently  advanced  to  give  hope  for  the  birth  of  a  living  child,  we 
would  not,  of  coui-se,  resort  to  this  expedient  unless  the  mother's  health 
was  seriously  im})erilled.  It  is  possible  that  in  such  ca.ses  the  patient 
might  be  relieved  by  inserting  the  minute  needle  of  an  asjiirator 
through  the  os  and  removing  a  certain  quantity  of  the  liquor  amnii 


PATIIOLOaV  OF  THE  DECIDUA   AND   OVUM.  241 

by  aspimtioii,  without  induoiiii:;  tlie  labor.     I  have  never  had  an  oppor- 
tunity of  ti'vino-  this  expe(Hent,  but  it  neenis  a  possibility. 

Deficiency  of  Liquor  Aninii. — A  defective  amount  of  liquor  aninii 
is  said  to  favor  eertain  malformations,  by  allowing  the  uterus  to  com- 
])ress  the  foetus  unduly.  It  certainly  occasionally  gives  rise  to  adhesion 
l)etween  the  foetus  and  the  membranes,  and  to  the  formation  of  amniotic 
bands  which  are  capable  of  producing  certain  iijetal  deformities  (pp.  2o'S 
and  244). 

The  liquor  amnii  itself  varies  much  in  appearance.  It  is  sometimes 
thick  and  treacly,  instead  of  limpid,  and  it  may  be  offensive  in  odor. 
The  cause  of  these  variations  is  not  well  understood. 

Pathology  of  the  Foetus. — There  is  abundant  evidence  that  the 
foetus  in  ntero  is  subject  to  many  diseases,  some  of  which  cause  its 
death,  and  others  leave  distinct  traces  of  their  existence,  although  not 
]>ro.ving  fatal.  The  subject  is  of  great  importance,  and  is  well  worthy 
of  study.  There  is  still  much  to  be  done  in  this  direction,  which  may 
lead  to  important  practical  results.  I  can,  however,  do  little  more 
than  enumerate  some  of  the  principal  affections  which  have  been 
observed. 

Diseases  Transmitted  through  the  Mother. — It  is  a  well-estab- 
lished fact  that  the  various  eruptive  fevers  from  which  the  mother  may 
suffer  may  be  communicated  to  the  foetus  in  utero.  When  the  mother 
is  attacked  with  confluent  small-pox  she  almost  always  aborts,  but  not 
necessarily  so  when  it  is  discrete  or  modified.  In  such  cases  it  has  often 
happened  that  the  foetus  has  been  born  with  evident  marks  of  small- 
poK.  Cases  are  on  record  which  prove  that  the  foetus  was  attacked 
subsequently  to  the  mother.  Thus,  a  mother  attacked  with  small-i)0X 
has  miscarried,  and  has  given  birth  to  a  living  child  showing  no  trace  of 
the  disease,  which,  however,  showed  itself  in  two  or  three  days;  proving 
that  it  had  been  contracted  and  had  run  through  its  usual  period  of  in- 
cubation when  the  foetus  was  still  in  utero.  It  does  not  follow,  however, 
that  the  foetus  is  affected,  as  Serres  has  collected  22  cases  in  which  women 
suffering  from  small-pox  gave  birth  to  children  who  had  not  contracted 
the  disease.  It  has  been  supposed  that  in  such  cases  the  child  is  pro- 
tected from  small-pox,  though  it  has  shown  no  symptom  of  having  had 
the  disease.  Tarnier,  however,  cites  two  instances  in  which  such  chil- 
dren had  small-pox  two  years  after  birth.  INIadge  and  Simpson  record 
cases  in  which  vaccination  performed  on  the  mother  during  pregnancy 
protected  the  foetus,  on  whom  all  subsequent  attempts  at  vaccination 
failed.  There  is  evidence  also  to  prove  that  the  disease  may  be  trans- 
mitted to  the  foetus  through  a  mother  who  is  herself  unsusceptible  of 
contagion,  the  child  having  been  covered  with  small-pox  eruption,  the 
mother  being  quite  free  from  it.  It  is  probable  that  the  same  facts 
\vhich  have  been  observed  Avitli  regard  to  small-pox  hold  true  with 
reference  to  other  zymotic  diseases,  such  as  ^arlet  fever  and  measles, 
although  there  is  not  sufficient  evidence  to  justify  a  positive  asser- 
tion to  that  effect. 

Amongst  other  maternal  diseases,  malaria  and  lead-poisoning  are 
known  to  aflTcct  the  foetus  in  idcro.  Dr.  Stokes  relates  cases  in  which 
the  mother  suffered  from  tertian  ague,  the  child  having  also  attacks,  as 

16 


LM2  PflEf.XAXCy. 

cvidt'iict'd  l)y  its  convulsive  iiKiNciiiciits,  jipprociahlc  l)V  the  motlu'r, 
Avliich  took  i)laoo  at  tlic  regular  interval^,  hut  at  a  (lifl'd-cnt  tinu;  iVoni 
the  mother's  paroxysms.  In  otlier  cases  the  febrile  paroxysm  comes  on 
at  the  same  time  in  the  foetus  as  in  tlie  mother;  and  the  fact  has  been 
verified  by  the  oi)Servation  tiiat  the  paroxysms  continued  to  rei-ni- 
simnhancously  aliter  delivery.  Tlie  iu-tus  has  also  been  b(»rn  with  dis- 
tinct malarious  enlarii'cment  <tl"  the  spleen.  From  the  f're(juencv  with 
which  largely  hypertroj)hied  spleens  are  seen  in  mere  inl'ants  in  mala- 
rious districts  I  imagine  that  the  intra-uterine  disease  must  be  common. 
I  have  frequently  observed  this  fact  in  India,  althougli,  of  coui'se,  Mith- 
out  any  possibility  of  ascertaining  if  the  mothers  had  suffered  from 
intermittent  fever  during  pregnancy.  Lead-poisoning  is  also  kiutwn  to 
have  a  most  prejudicial  cHect  on  the  fetus,  and  Irefpiently  to  lead  to 
abortion,  M.  Paul  has  collected  81  cases'  in  which  it  caused  the  death 
of  the  foetus,  in  some  not  until  after  birth;  and  occasionally  it  seems  to 
have  affected  the  foetus  even  Avhen  the  mother  escaped. 

Of  all  blood-dyscrasife  transmitted  to  the  foetus,  the  most  important 
is  syphilis.  Its  influence  in  producing  repeated  abortion  is  elsewhere 
described  (j).  251).  It  may  unijuestionably  be  transmitted  to  the  fijetus 
without  producing  abortion,  and  at  term  the  mother  may  be  either 
delivered  of  a  living  child  bearing  evident  traces  of  the  disea.se,  of 
a  dead  child  similarly  affected,  or  of  an  apparently  healthy  child  in 
Avhoni  the  disease  develops  itself  after  a  lapse  of  a  month  or  two. 
These  varying  effects  probably  depend  on  the  intensity  of  the  poison  ; 
and  the  longer  the  time  has  elapsed  since  the  origin  of  the  disease  in 
the  affected  parent  the  better  will  be  the  chance  for  the  child.  (The 
disease  is  no  doubt  generally  transmitted  through  the  mother,  and  if  she 
be  affected  at  the  time  of  conception  the  infection  of  the  foetus  seems 
certairA  If,  however,  she  contracts  the  disease  at  an  advanced  ])eriod 
of  ]3regnancv,  the  child  may  entirely  cscajie.  Ricord  even  believes  that 
syphilis  contracted  after  the  sixth  month  of  })regnancy  never  atlects  tiie 
child.  (The  father  alone  may  transmit  the  disease  to  the  ovum  •)  and 
Hutchinson  has  recorded  cases  to  show  that  the  mother  may  become 
secondarily  affected  through  the  diseased  foetus.  The  evidences  of 
svphilitic  taint  in  a  living  or  dead  child  are  sufficiently  characteristic. 
The  child  is  generally  ])uuv  and  ill-developed.  An  eruption  of 
pemphigus  is  common — either  fully-developed  bid  Ire  or  their  <'arly 
stage,  when  they  form  circular  copper-colored  i)atches.  This  eru})tion 
is  always  most  marked  on  the  hands  and  feet,  and  a  child  born  with 
.such  an  eruption  may  be  certaiidy  considered  syphilitic.  On  ]iost- 
mortem  examination  the  most  usual  signs  are  small  ])atches  of  sup))uni- 
tion  in  the  thynnis,  similar  localized  sujipui-ations  in  the  tissues  of  the 
lungs,  indurated  yellowish  jiatches  in  the  liver,  and  ])erifonitis,  the  im- 
portance of  whicii  in  causing  the  death  of  syphilitic  children  has  been 
specially  dwelt  on  by  Simpson.^ 

The  most  imjiortant  of  the  inflammatory  diseases  affecting  the  foetus 
is  peritonitis.  Simpson  has  shown  that  traces  of  it  are  \ery.  fre<|uently 
met  with,  and  that  it  is  not  always  syphilitic.  Sometimes  it  has  been 
ob-served  when  the  mother  has  been  in  bad   h<'alth  during  pregnancy, 

'  Arch.  gen.  de  Ned.,  ISGU.  -'  Ob^t.  Worh,  vol.  i.  \>.  117. 


PATIIOLOdY   OF  THE   DECIDUA   AND   OVUM.  243 

and  at  others  it  secius  to  have  resuhed  from  sf)iii('  morbid  condition  of 
the  fcetal  viscera,  Plenrisy  with  effusion  is  anotiicr  inflammatorv  aili'c- 
tion  which  has  been  noticed. 

The  dropsical  alfections  most  generally  met  M'ith  are  ascites  and 
livdrocpj^^hidiis  which  may  both  have  the  effect  of  impeding  clefivery. 
Of  these,  hydrocej>halns  is  the  more  common,  and  may  give  rise  to 
much  difficulty  in  labor.  Its  canses  are  nncertain,  but  it  prolxibly  de- 
pends on  some  altered  state  of  the  mother's  health,  as  it  is  apt  to  recur 
in  several  successive  pregnancies,  and  is  not  infrequently  associated  with 
an  imperfectly-developed  vertebral  column  and  spina  bifida.  The  fluid 
collects  in  the  ventricles,  which  it  greatly  distends,  and  these  then  pro- 
duce expansion  and  thinning  of  the  cranium,  the  bones  of  which  are 
^\•idely  sei)arated  from  each  other  at  the  sutures,  which  are  prominent 
and  fluctuating.  In  a  few  cases  internal  hydroce[)halus  may  be  com- 
]>licated,  and  the  diagnosis  in  labor  consequently  obscured  by  the  coex- 
istence of  what  has  been  called  "external  hydrocephalus."  This  cou- 
sists  of  a  collection  of  fluid  between  the  skull  and  the  scalp,  which  may 
be  either  formed  there  originally  or  ma}^  collect  from  a  rupture  of  one 
of  the  sutures  or  fontanelles  during  labor,  through  wdiich  the  intracranial 
fluid  escapes. 

Ascites  is  generally  associated  with  hydramuios,  and  sometimes  with 
hydrothorax  or  other  dropsical  effusions.  It  is  a  rare  affection,  and 
according  to  Depaul '  extreme  distension  of  the  bladder  is  not  infre- 
quently mistaken  for  it. 

Tumors  of  different  kinds  may  be  met  with  in  various  parts  of  the 
chikTFbody,  which  sometimes  grow  to  a  great  size  and  impede  delivery. 
Tarnier  records  cases  of  meningocele  larger  than  a  child's  head,  and 
large  cystic  growths  have  been  observed  attached  to  the  nates,  pectoral 
region,  or  other  parts  of  the  body.  Cancerous  tumors  of  considerable 
size,  either  external  or  of  the  viscera,  have  also  been  met  with.  Other 
foetal  tumors  may  be  produced  by  congenital  deformities,  such  as  projec- 
tion of  the  liver  or  other  abdominal  viscera  through  a  deficiency  of  the 
abdominal  wall ;  or  spina  bifida  from  imperfectly-developed  vertebrae. 
The  amount  of  dystocia  produced  by  such  causes  will,  of  course,  vary 
much  in  proportion  to  the  size,  consistency,  and  accessibility  of  the 
tumor.  I 

Wounds  and  Injuries  of  the  Pootus.— iAecidents  of  serious  gravity 
to  the  fretus  may  happen  from  violence  to  which  the  mother  has  been 
subjected,  such  as  falls  or  blows,  without  necessarily  interfering  with 
gestation./  Many  curious  examples  of  this  kind  are  on  record.  Thus,  a 
child  has  been  born  presenting  a  severe  lacerated  wound  extending  the 
whole  length  of  the  spine,  Avhere  both  the  skin  and  the  muscles  have 
been  torn,  and  which  seems  to  have  resulted  from  the  mother  having 
fallen  in  the  last  month  of  pregnancy.  Similar  lacerations  and  contu- 
sions have  been  observed  in  other  parts  of  the  body,  the  wounds  being 
in  various  stages  of  cicatrization  corresponding  to  the  lapse  of  time  since 
the  accident  had  occurred.  Intra-u ferine  fractures  are  not  rare,  ap])ar- 
ently  arising  from  similar  causes.  In  some  of  these  cases  the  broken 
ends  of  the  bones  had  united,  but,  from  want  of  accurate  apposition,  at 

'  Tarnier's  Cazcanx,  p.  855. 


244 


pni:(;yA\cy. 


Fig.  95. 


."Ill  acute  antrlc,  so  as  to  <>:iv('  rise  to  imicli  siibscquont  (loforiiiity. 
C'liaiissior  records  two  ca.scs  in  Aviiicli  tliere  were  many  Iractiires  in  the 
sjuue  child — in  one  113,  .and  in  another  42 — which  were  in  different 
.stages  of  i-epair.  He  attributes  this  curion.s  occurrence  to  some  con- 
genital delect  in  the  nutrition  of  the  hones,  possibly  allied  to  mollities 
ossiuni.' 

Intra-nterine  amputations  of  fa?tal  lind)s  have  not  nnfrcijuently  been 
observed.     Children  are  occasionally  born  Avith  one  extremity  more  or 

less  completely  absent,  and  cases  are  known 
in  which  the  whole  four  extremities  were 
wanting  (Fig.  95).  The  mode  in  which  these 
malformations  are  produced  has  given  rise  to 
much  discussion.  At  one  time  it  was  suj)- 
])osed  that  the  deficiency  of  the  limb  was  due 
to  gangrene  of  the  extremity  and  subscfpient 
separation  of  the  sphacelated  ])arts.  Iteu.ss, 
who  has  studied  the  whole  .subject  very 
minutely,-  considers  gangrene  in  the  nnru])- 
tured  ovum  to  be  an  impossibility,  for  that 
change  cannot  occur  unless  there  is  access  oi" 
oxygen  ;  and  when  portions  of  the  .separated 
extremity  are  found  in  utero,  as  is  often  the 
case,  they  show  evidences  of  maceration,  but 
not  of  decomposition.  ((The  geneiid  belief  isj 
that  these  intra-uterine  amjiutntions  depend' 
on  constriction  of  the  limb  by  folds  or  bands' 
of  the  amnion — most  often  met  with  when 
the  liquor  aranii  is  deficient  in  quantity — 
which  obstruct  the  circulation  and  thus  give  rise  to  atroj)hy  of  the  part 
below  the  constriction||  It  has  been  su})posed  that  the  umbilical  cord 
might,  by  encircling  tne  limb,  produce  a  like  result.  It  a]>pears  doubt- 
ful, however,  whether  this  cause  is  sufficient  to  j)roduce  com])lete  sejia- 
ration  of  the  limb,  as  any  great  amount  of  constriction  would  interfere 
with  the  circulation  through  the  cord.  )  Sometimes,  when  intra-uterine 
amputation  occurs,  the  separated  portion  of  the  limb  is  found  lying  loose 
in  the  amniotic  cavity,  and  is  expelled  after  the  child.  Cases  of  this  kind 
have  been  recorded  by  Martin,  Chaussier,  and  AVatkinson.  ^Nloi-e  often 
no  trace  of  the  separated  extremity  can  be  found.  The  explanation 
probably  depends  upon  the  period  of  utero-gestation  at  which  amputa- 
tion took  ])lace.  If  it  occurred  at  a  very  early  period  of  ])regnancy, 
before  the  third  month,  the  detached  portion  would  be  minute  and  soft 
and  would  easily  disa])pear  by  .solution.  If  at  a  later  period,  this 
could  hardly  hajjpcn  and  the  detached  portion  would  remain  /;/  vfrro. 
In  cases  of  the  latter  kind  cicatrization  of  the  stump  has  often  been 
observed  to  be  incomplete.  (  Simjison  pointed  out  the  occasional  exist- 
ence of  rudimentary  fingers  or  toes  on  the  stumj^of  an  amjiutated  limb, 
such  as  are  seen  on  the  thighs  in  Fig.  95.  jt  These  lie  attributed  to  an 
abortive  reproduction  of  the  separated  exti'emity,  analogous  to  what  is 
observed  in  some  of  the  lower  animals.    This  explanation  has  been  con- 

'  Gazette  hebdom.,  1860.  '  Scanzoni's  Bcitriigc,  1869. 


Intra-utcriiic     Ampiuation 
Ijotli  Arms  and  Legs. 


of 


rATllOLOdV  OF  THE  DKCIDrA   AM)   OVUM.  'lA') 

tested  with  luiich  show  of  reason.  Martin  believes  that  tlie  rej)ro(hi(> 
tion  is  only  apparent,  and  that  the  rudimentary  extremities  are,  in 
reahty,  instanees  t>f  arrested  devek»])ment.  The  eonstrietln<^  agents 
interfered  with  the  eirculation  sufficiently  to  arrest  the  growth  of"  the 
limb  below  the  site  of"  constriction,  but  not  sufficiently  to  effect  complete 
separation.  If  constriction  occurred  at  a  very  early  stage  of  develop- 
ineut,  an  appearance  similar  to  that  observed  by  Simpson  would  be  pro- 
duced. It  does  not  follow,  however,  that  all  cases  of  absence  of 
limbs  depend  on  intra-utcriue  amputations.  (  In  some  cases  they  would, 
appear  to  be  the  result  of  a  spontaneous  arrest  of  development  or  of  con-' 
genital  moustrosityJ  Mr.  Scott '  relates  a  case  in  which  a  distinct 
hereditary  tendency  was  evident ;  and  here  the  deformity  certainly 
could  not  have  resulted  from  the  constriction  of  amniotic  bands.  In 
this  family  the  grandfather  had  both  forearms  wanting,  with  rudi- 
nientary  fingers  attached  ;  the  next  generation  escaped,  but  the  grand- 
child had  a  deformity  precisely  similar  to  the  grandfather. 

[Arrested  Pullulation.-t-The  absence  of  a  hand  w^here  there  are  ru- 
dimentary evidences  of  an  attempt  to  form  the  thumb  and  fingers  can 
be  accounted  for  much  more  satisfactorily  on  the  theory  of  an  arrested 
development  taking  place  in  the  latter  half  of  the  second  month  of 
embryonic  life  than  upon  the  hypothetical  idea  that  there  has  been  first 
an  amputation  in  utero,  and  then  an  attempt  of  nature  to  reproduce  the 
lost  digits  by  a  new  budding  process,  as  taught  by  Simpson  and  Annan- 
dale.  \  More  than  thirty  years  ago  I  became  fully  satisfied  that  there 
was  an  inclination  in  nature  to  repeat  itself  so  exactly  during  the  pullu- 
lative  period  of  embryonic  growth  that  cases  of  congenital  deficiency  of 
the  thumb  and  fingers  of  a  precisely  similar  character  must  from  time 
to  time  present  themselves  to  the  eye  of  the  medical  observer.  It  so 
happened  that  three  such  typical  cases,  all  exactly  alike,  in  two  boys  and 
one  girl,  each  being  strangely  without  the  left  hand,  came  under  my 
notice  during  a  short  period  of  years.  The  forearm  in  each  ended  in  a 
well-rounded  and  slightly-flattened  stump,  from  which  protruded  a  row 
of  pisiform  nailless  bodies  representing  the  embryonic  commencement  of 
the  formation  of  a  thumb  and  four  fingers.  I  saw  these  subjects  at 
different  ages  of  infancy  and  childhood,  and  the  little  pea-like  bodies 
remained  the  same,  with  the  exception  that  they  became  slightly  larger. 
In  a  fourth  case,  a  boy,  the  finger-rudiments  were  entirely  absent,  and 
there  was  an  attempt  to  form  a  thumb,  which  was  useless  and  about 
three-quarters  of  an  inch  long  :  the  boy  developed  into  a  powerful  man 
of  six  feet.  Cases  of  the  precise  type  of  the  three  first  named  have  come 
under  the  observ^ation  of  medical  friends. — Ed.] 

Death  of  Fcetus.— (-When  from  any  cause  the  foetus  has  died  during 
pregnancy,  it  may  be  either  soon  expelled,  or  it  may  be  retained  in  utcro 
for  a  longer  or  shorter  time  or  even  to  the  full  period.'  The  changes 
observed  in  such  foetuses  vary  considerably  according  to  the  age  of  the 
fetus  at  the  time  of  death  or  the  time  that  it  has  been  retained  //;  utero. 
If  it  die  at  an  early  period,  when  the  tissues  are  very  soft,  it  may  entirely 
dissolve  in  the  liquor  amnii,  and  no  trace  of  it  may  be  found  when  the 
mendjranes  are  expelled.     Or  it  may  shrivel  or  mummify;  and  if  this 

'  Obst.  Trans.,  1872,  vol.  xiii,  p.  94. 


246  j'j:Jx;.\Aycy. 

happoM  in  a  twin  pirgnancy,  as  sometimes  oceiirs,  tli«!  f;ru\ving  fittus 
may  compress  aiul  tiatteii  the  dead  one  against  the  uterine  waU. 

At  a  hiter  period  of  pregnanev  a  <h'ad  iietus  undergoes  changes 
ascribed  to  pntrelaetioii,  but  which  produce  appearances  ditlerent  Jrom 
those  of  decomposition  in  animal  textures  exposed  to  the  atmosphere. 
There  is  no  olfensive  smell,  as  in  ordinary  decay.  The  tissues  are  all 
soltcncd  and  flaccid.  The  more  manifest  changes  are  in  the  skin,  the 
epidermis  of  which  is  separated  from  the  cutis  vera,  which  lias  a  deej) 
reddish  color.  This  is  especially  apparent  on  the  abdomen,  which  is 
flaccid,  and  hollow  in  the  centre.  The  internal  organs  are  much 
altered.  The  brain  is  diffluent  and  pulpy,  and  the  cranial  bones  loose 
within  the  scalp.  The  structures  of  the  muscles  and  viscera  are  in 
various  stages  of"  transformation,  many  having  undergone  fatty  changes, 
and  contain  crystals  of  margarin  and  eholesterin.  "^fiie  extent  to  Mhidi 
these  changes  occur  depends,  in  a  great  measure,  on  the  length  of  time 
the  fcetus  has  been  dead,  but  they  do  not  admit  of  our  estimating  with 
any  degree  of  accuracy  M'hat  that  time  has  been. 

The  symptoms  and  diagnosis  of  the  death  of  the  foetus  may  here 
be  considered.  They  are,  unfortunately,  not  very  reliable.  The  cessa- 
tion of  the  f(etal  movera£ut.^  cannot  be  depended  on,  as  they  are  fre- 
quently unfelt  for  days  or  Avceks  when  the  child  is  alive  and  well. 
Sometimes  the  death  of  the  foetus  is  preceded  by  its  irregular  and 
tumultuous  movements,  and  in  women  who  have  been  delivered  of 
several  dead  children  in  succession  this  sensation  may  guide  us  in  our 
diagnosis.  This  suspicion  may  be  confirmed  by  auscultation.  The 
mere  fact  that  we  are  unable  at  any  given  time  to  hear  the  fatal  heart 
Avill  not  justify  an  opinion  that  the  fo'tus  is  dead.  If,  however,  the 
foetal  heart  has  been  distinctly  heard,  and  after  one  or  two  careful 
examinations,  repeated  at  separate  times,  it  cannot  again  be  made  out, 
the  probability  of  the  child  being  dead  may  be  assumed.  Certain 
changes  in  the  mother's  health  have  been  noted  in  connection  with  the 
death  of  the  f(rtus,  such  as  depression  and  lowness  of  spirits,  a  feeling 
of  coldness  and  weight  about  the  lower  parts  of  the  abdomen,  ])alcness 
of  the  face,  a  livid  circle  roinid  the  eyes,  irregular  shiverings  and  fever- 
ishness,  shrinking  of  the  breasts,  and  diminution  in  the  size  of  the 
abdominal  tumor.  All  these,  hoAvever,  are  too  indefinite  to  justify 
a  positive  diagnosis,  and  they  are  not  infrequently  altogether  absent. 
At  most  they  can  do  no  more  than  cause  a  suspicion  as  to  what 
has  happened. 


ABOUTION  AND  PREMATURE  LABOR.  241 


CHAPTER  X. 

ABORTION  AND  PEP:MATURE  LABOR. 

Importance  and  Frequency  of  Abortion. — The  premature  expul- 
wion  of  the  ftietns  is  aii  eveut  of_  great  frequency.  The  number  of 
foetal  lives  thus  lost  is  enormous.  There  are  few  multipara  who  have 
not  aborted  at  one  time  or  other  of  their  lives.  Hcgcr  estimates  that 
about  1  abortion  occurs  to  every  8  or  10  deliveries  at  term.  White- 
head has  calculated  that  at  least  90  per  cent,  of  married  women  who 
lived  to  the  change  of  life  had  aborted.  \  The  influence  of  this  inci- 
dent on  the  future  health  of  the  mother  is  also  of  great  importance.\ 
It  rarely,  indeed,  proves  directly  fatal,  but  it  often  produces  great  debil- 
ity from  the  profuse  loss  of  blood  accompanying  it ;  and  it  is  one  of 
the  most  prolific  causes  of  uterine  disease  in  after-life,  possibly  because 
Avomen  are  apt  to  be  more  careless  during  convalescence  than  after 
delivery,  and  the  proper  involution  of  the  uterus  is  thus  more  fre- 
quently interfered  with. 

Definition. — A  not  uncommon  division  of  the  subject  is  into  abor-  \ 
Hon,  miscarriage,  and  premature  labor  jihe  first  name  being  applied  to  I 
expulsion" of 't'he  ovum  b'efore  the  end  of  the  fourth  mouth  of  utero-( 
gestatioi^^.  miscarriage,  to  expulsion  from  the  end  of  the  fourth  to  thej 
end  of  the  sixth  month J|  and  premature  labor,  to  expulsion  from  thej^,*^^ 
end  of  the  sixth  mouth  to  the  term  of  pregnancy .^^    This  is,  however,  a 
needless  and  confusing  subdivision  which  leads  fo  no  practical  result. « 
Itsufficc.s  to  apply  the  term  "abortion"  or '^  miscarriage  "  indiscrim- 
inately to  all  cases  in  which  pregnancy  is  terminated  before  the  foetus 
has  arrived  at  a  viable  age,  and  "  premature  labor  "  to  those  in  which 
there  is  a  possibility  of  its  survival.     [There  is  little  or  no  hope  of  a  / 
foetus  living  before  the  twent^;;;eighth  Sveek,  or  seventh  lunar  month,// 
and  this  period   is  therefore  geTieraTly  fixed  on   as  the  limit  betweenW 
])remature  labor  and  abortion.  \  The  rule  is,  however,  not  without  aul 
occasional,  although  very  rare,-€'xceptiou.     Dr.   Keiller  of  Edinburgh 
lias  recorded  an  instance  in  which  a  foetus  was  born  alive  at  the  fourth 
mouth,  nine  days  after*  the  mother  liad  experienced  the  sensation  of 
quickening.     I  myself  recently  attended  a  lady  who  miscarried  in  the 
fifth  month  of  pregnancy,  the  child  being  born  alive  and  living  for 
three  hours.     Several  cases  are  on  record  in  which  after  delivery  in  the 
sixth  month  the  child  survived  and  was  reared.     The  possibility  of  the 
birth  of  a  living  child  under  such  circumstances  should  be  recognized, 
as  it  may  give  rise  to  legal  questions  of  importance  ;  but  the  exceptions 
to  the  ordinary  rule  are  so  rare  that  they  need  not  interfere  with  the 
division  of  the  subject  usually  made. 

Abortion  is  most  Common  in  Multiparse.— flNIultipara?  abort  far 
more  frequently  than  priniipar;i.>\  This  is  contrari'  to  the  statement  in 
many  obstetrical  works.     ThuSj^HCyler  Smith  says  ''  there  seems  to  be  a 


V 


248  i'A'AY.Xl.VCr. 

j^roator  (laiijj^cr  of  tliis  accident  in  llic  first  ])rc<rnancy."  Schrocdcr,' 
liowevcr,  states  that  23  innlti|)ai-{e  alxnl  to  .">  j)rinii])ai-ic  ;  and  Dr. 
Whitehead  of  Manchester,  wlio  has  particidarly  studied  the  sul)je(t, 
beheves  that  aboi'tioii  is  inore  apt  to  occur  ;dter  the  third  and  I'ourlli 
pregnancies,  especially  Avhon  these  take  place  toward  the  time  for  the 
cessation  of  menstruation. 

\There can  be  no  doubt  that  women  who  ha\-e  aborted  more  than  once 
are  ju'culiarly  liable  to  a  recurrence  of  the  aci-ident.^  'J'his  can  <j:;eneiallv 
be  traced  to  the  existence  of  some  j)redis|)osing  cause  which  persists 
throuiih  several  pret>:nancics ;  as,  for  exainj)le,  a  syj)hilitic  t:<int,  a  ute- 
rine ricxion,  or  a  morbid  state  of  the  lining  membrane  of  the  uterus. 
It  is  probable  that  in  many  women  a  recurrence  of  tlie  accident  induces 
a  habit  of.abQrtion.  or  jierhajis  it  might  be  more  accurate  to  say  a  pecu- 
liai'  irritable  condition  of  the  uterus,  which  renders  the  ci)ntinuance  of 
jnvgnancy  a  matter  of  difficulty  independently  of  any  recognizaljle 
organic  cause. 

The  frequency  of  abortion  varies  much  at  different  periods  of  ]>reg- 
iiancy,  and  it  occurs  much  more  often  in  the  early  months,  because  of 
the  com})aratively  slight  connection  then  existing  between  the  chorion 
and  the  decidua.  At  a  very  early  period  of  })i-egnancy  the  ovum  is  cast 
off  with  such  facility,  and  is  of  such  minute  size,  that  the  fact  of  abor- 
tion having  occurred  passes  unrecognized.  Very  many  cases  in  which 
the  patient  goes  one  or  two  weeks  over  her  time,  and  then  lias  what  is 
supposed  to  be  merely  a  more  than  usually  profuse  period,  are  probably 
instances  of  such  early  miscarriages.  A'elpcau  detected  an  ovum  of 
about  fourteen  days  which  was  not  larger  than  an  ordinary  pea,  and  it  is 
easy  to  understand  how  so  small  a  body  should  pass  unnoticed  in  the 
blood  which  escapes  along  with  it. 

Up  to  the  end  of  the  third  month,  when  miscarriage  occurs,  the  ovum 
is  generally  (jast  off  enjncm^,  the  decidua  subsecpiently  coming  away  in 
shreds  or  as  an  entire  membrane.  The  abortion  is  then  comparatively 
easy.  From  the  third  to  the  sixth  month,  after  the  j)laccnta  is  formed, 
the  amnion  is,  as  a  rule,  first  ruptured  by  the  ntei-inc  contractions  and 
the  foetus  is  expelled  by  itself.  The  placenta  and  membranes  may  then 
be  shed  as  in  ordinary  labor.  It  often  hapj)cns,  however,  that  on 
account  of  the  firmness  of  the  placental  adhesion  at  this  jieriod  the 
secundines  are  retained  for  a  greater  or  less  length  of  time.  This  sub- 
jects the  patient  to  many  risks,  especially  to  those  of  profuse  hemoi- 
rhagc  and  of  se})tica?mia.  For  this  reason  jn'emature  termination  of 
the  jM'egnancy  is  attended  by  much  greater  danger  to  the  mother  between 
the  third  and  sixth  months  than  at  an  earlier  or  later  date.  After  the 
sixth  month  the  course  of  events  is  not  different  from  that  attending 
ordinary  labor.  The  ])rognosis  to  the  child  is  more  unfavorable  in  ]>ro- 
])ortion  to  the  distance  from  the  full  jK'riod  of  gestation  at  which 
premature  labor  takes  place. 

Causes. — The  causes  of  abortion  mav  conveniently  be  subdivided 
into  the  prcjUspo.sinr/  and  c.vcifiii(/,  the  latter  being  often  slight,  and  such 
as  would  have  no  effect  inlnducing  uterine  contractions  in  women 
unless  associated  with  one  or  more  of  the  fonner  class  of  causes.     The 

'  Schroeder,  3Ianu<d  of  MiihviJ'cnj,  p.  149. 


ABORTIOy  AND   PREMATURE  LABOR. 


249 


(predisposition  to  ahortion  may  depend  on  some  eondition  interfering  . 
with  the  vitality  of  the  ovum  or  its  relation  to  the  maternal  structures,! 
iiv  on  certain  conditions  directly  afl'ectino;  the  mother's  health.     ' 

lOne  of  the  most  common  antecedents  of  ahortion  is  the  death  of  the 
foetus.Uvhich  leads  to  secondary  changes  and  ultimately  pnxhu'cs  the 
uterine  contractions  which  end  in  its  expulsion.  The  precise  causes  of 
death  in  any  given  case  cannot  always  be  accurately  ascertained,  as  they 
sometimes  depend  on  conditions  which  are  traceable  to  the  maternal 
structures,  at  others  to  the  ovular,  or,  it  may  be,  to  a  combination  of 
the  two.  Nor  does  it  by  any  means  follow  that  the  death  of  the  ovum 
immediately  results  in  its  expulsion.  (The  mode  in  which  death  of  tliej 
ovum  produces  abortion  is  not  difficult  to  understand,  for  it  necessarily  I 
leads  to  changes  in  the  relations  between  the  ovular  and  maternal  struc- 
tures :  these  changes  cause  hemorrhages — partly  external  and  partly 
into  the  membranes — which  in  their  turn  excite  uterine  contraction. 
Extravasations  of  blood  may  take  place  in  various  positions.  One  of 
the  most  common  is  into  the  decidual  cavity,  between  the  decidua  vera 
and  the  decidua  reflexa,  or  between  the  decidua  vera  and  the  uterine 
walls.  If  the  hemorrhage  is  only  slight,  and  especially  if  it  comes 
from  that  portion  of  the  decidua  near  the  internal  os  and  at  a  distance 
from  the  ovum,  there  need  be  no  material  separation  and  pregnancy 
may  continue.  This  explains  the  cases  occasionally  met  with  in  which 
there  is  more  or  less  hemorrhage  without  subsequent  abortion.     When 

Fig.  96. 


An  Apuplectic  Ovum,  with   blood  effused  in  masses  under  the  total  surface  of  the  mem- 
branes. 


the  amount  of  extravasated  blood  is  at  all  great,  separation  and   abor- 
tion necessarilv  result,  and  the  decidua  will  be  found  on  expulsion  to 


li.")(l 


j'RhvyAycY. 


liavf  coa^inla  on  its  sui'lacf  and  lictwccii  its  sarioiis  layers,  uliicli  aiv 
foiiiul  to  project  into  the  cavity  of  the  aiiiulon  (Fi^.  9Gj.  In  other 
cases  li(Mnorrhas!;e  is  still  more  extensive,  and,  after  hreakintj^  (hrout;h 
the  decidna  rcilexa,  forms  clots  hctween  it  and  the  chorion,  and  even  in 
tiie  cavitv  ot"  the  amnion,  Snpiiosinjj;  expulsion  to  take  j)lace  shortly 
alter  euagula  are  deposited  among  the  membranes,  the  blood  is  little 
altered  and  we  have  an  ordinary  abortion.  \  If,  however,  the  ovum  is 
retained,  the  coairnlated  fibrin  and  the  ])la('enta  or  membranes  uudero;*) 
secondary  changes  which  lead  to  the  formation  of  moles,  Tlie  so-called 
Jicaliy  mole  (Fig".  -'T)  is  often  retained  for  many  weeks  or  months  after 

Kk;.  97. 


Blighted  0\Tam,  with  fleshy  dL-generation  of  the  membranes. 


the  death  of  the  ftetus,  and  duiing  this  time  there  may  be  Init  little 
modification  of  the  usual  sym]itoms  of  pregnancy  ;  or,  as  is  frequently 
the  ca.se,  it  gives  rise  to  occasional  hemorrhage,  until  at  last  uterine  con- 
tractions come  on,  and  it  is  east  off  in  the  form  of  a  thick  fleshy  ma.-vs 
having  but  little  resemblance  to  the  ordinary  ])roducts  of  conce|)tioiu 
The  most  probable  explanation  of  its  formation  is  that  Avhen  hemor- 
rhage originally  took  ])lace  the  efliision  of  blood  was  not  stiflicient  to 
effect  the  entire  separation  and  expulsion  of  the  ovum.  Part  of  the 
membranes  or  of  the  placenta — if  that  organ  had  commenced  to  forni 
— retained  its  organic  ccmnection  with  the  uterus,  Avhile  the  footus  jier- 
ished.  The  attached  jiortion  of  the  placenta  or  membranes  continues 
to  be  nourished,  althotigh  al)normally.  The  f(vtus  generally  entirely 
di.<ap})ears,  especially  if  it  has  jK'rished  at  an  early  ])eriod  of  utero-ges- 
tation,  when  it  becomes  dissolved  in  the  liquor  anniii  ;  or  it  may 
become  macerated,  shrivelled,  and  greatly  altered  in  ai^ixiu'ancc.  The 
effused  blood  becomes  decolorized  from  the  absorption  of  the  corpus- 
cles, and,  according  to  Scanzoni,  fresh  vcSvSels  are  developed  in  the  fibrin, 
which  increase  the  vascular  attachment  of  the  mole  to  the  uterine  walls. 


ABORTION  AND   I'REMATritE   LAHOJL  2.")] 

The  |)la('cnta  and  inciiiWraiics  may  go  on  increasing-  in  thickness  nnlil 
they  form  a  mass  of  considerable  size.  Careful  micr<tse(jpic  examina- 
tion will  almost  always  enable  us  to  discover  the  villi  of  the  chorion, 
altered  in  appearance',  often  loaded  with  granular  fatty  molecules,  but 
sufficiently  distinct  to  be  readily  recognizable. 

Important  as  are  the  causes  of  abortion  arising  from  some  morbid 
condition  of  the  ovum,  they  are  not  more  so  than  tiiose  which  depend 
on  the  maternal  state;  and  it  is  to  be  observed  that  the  former  are  often 
indirect  causes  produced  by  primary  maternal  changes,  ^lauy  of  these 
maternal  causes  act  by  causing  hypenemia,  of  the  uterus,  which  leads 
to  extravasation  of  blood.  Thus,  abortion  is  apt  to  occur  in  women 
who  lead  unhealthy  lives,  such  as  those  who  occupy  overheated  and  ill- 
ventilated  rooms,  or  ind_ulge  to  excess  in  the  fatigues  and  pleasures  of 
society,  in  the  use  of  alcoholic  drinks,  and  the  like.  Over-frequent 
coitus  has  been,  for  the  same  reason,  observed  to  produce  a  remarkable 
tendency  to  abortion,  and  Parent-Duchatelet  has  noted  that  it  is  of  very 
frequent  occurrence  amongst  women  of  loose  life.  Many;  _diseases 
strongly  predispose  to  it,  such  as  fevers,  zymotic  diseases  of  all  kinds, 
measles,  scarlet  fever,  small-pox,  and  diseases  of  the  respiratory  organs, 
such  as  ])roiichitis  and  pneumonia.  Syphilis  is  well  known  to  be  one 
of  the  most  frequent  causes,  and  one  tiiat  is  likely  to  act  in  successive 
pregnancies.  It  may  act  so  that  the  pregnancy  is  brought  to  a  prema- 
ture termination,  time  after  time,  until  the  constitutional  disease  is 
eradicated  by  appropriate  treatment.  It  acts  in  some  cases  through  the 
influence  of  the  father  in  producing  a  diseased  ovum  ;  and  it  is  the 
only  cause  wdiich  can  with  certainty  be  traced  to  the  state  of  the  father's 
health.  Many  other  morbid  conditions  of  the  blood  also  dispose  to 
abortion.  It  has  been  observed  to  be  a  frequent  result  of  lead-poison- 
ing, also  of  the  presence  of  noxious  gases  in  the  atmosphere,  such  as  an 
excess  of  carbonic  acid. 

Many  causes  act  throudi  the  ner^•ous  system,  such  as  fright,  anxiety, 
sudden  shock^  aud^  the  tike.  Thus'tliere  are  numerous  instances  on 
record  in  which  women  aborted  suddenly  after  the  receipt  of  some  bad 
news,  and  it  is  said  to  have  been  of  frequent  occurrence  in  women 
immediately  before  execution.  (The  influence  of  irritation  propagated 
through  the  nervous  system  from  a  distance,  tending  to  produce  uterine 
contraction  and  abortion  through  the  agency  of  reflex  action,  has  been 
specially  dwelt  uponT)y  Tyler  (SmithS  Thus  he  points  out  that  abor- 
tion not  unfrequently  occurs  from  the  irritation  of  constant  suckling  in 
women  who  become  pregnant  during  lactation.  (Tlie  eHect  of  suckling 
in  producing  uterine  contraction  is,  indeed,  well  known,  and  the  appli- 
cation of  the  child  to  the  breast  for  this  purpose  has  long  been  recog- 
nized as  a  method  of  treatment  in  post-])artum  hemorrhage."^  The 
irritation  of  the  trifacial  in  severe  toothache;  of  the  renal  nerves  in 
cases  of  gravel,  in  albuminuria,  etc.;  of  the  intestinal  nerves  in  exces- 
sive vomiting,  in  diarrhoea,  obstinate  constipation,  ascarides,  etc., — acts 
in  the  same  way.  We  may  i)erhaps  also  ex})lain  by  this  hypothesis 
the  fact  that  women  are  more  a[)t  to  abort  at  what  would  have  been  the 
menstrual  epoch  than  at  other  times,  as  the  ovarian  nerves  may  then  be 
subject  to  undue  excitement.     It  is  probable,  however,  that  there  may 


2.yj  pJijy.y.iy'CY. 

\)v  also  at  those  tiiiit's  more  or  k'ss  active  conircstioii  of  the  (leci(hia, 
wliich  may  predispose  to  hieeratioii  ol"  its  eapillaiies  aiitl  blood- 
ex  tea  vasat  ion.  tSiich  congestion  exists  in  those  ext-eptional  ceases  in 
which  menstruation  continues  for  one  or  more  periods  aiter  concep- 
tion, the  blood  probably  escaping;  from  the  space  between  the  decidua 
vera  and  refiexa;  and  thei'efore  there  is  no  reason  to  question  its 
also  happening  even  when  such  abnormal  menstruation  is  not 
present. 

Certain  plivsical  causes  may  produce  abortion  by  sej)arating  the 
ovum.  Thus  it  may  follow  a  fall,  a  blow,  or  other  accidents  of  a 
trivial  character.  On  the  other  hand,  women  may  be  subjected  to 
injuries  of  the  severest  kind  without  aborting.  The  probability, 
therefore,  is  that  these  a])parently  trivial  causes  only  o])erate  in 
women  who  for  .some  other  reason  are  })re(lisposed  to  the  accident. 
TJiis  is  borne  out  by  the  fact — which  is  well  known  in  these  days, 
wheu  the  artificial  production  of  abortion  is,  unhappily,  iar  from  a  very 
rare  event — that  it  is  by  no  means  easy  to  destroy  the  vitality  of  the 
foetus.  I  myself  know  of  a  case  in  which  the  uterine  sound  was  passed 
several  times  into  a  pregnant  uterus  without  ])roducing  abortion,  the 
pregnancy  proceeding  to  term.  Oldham  has  related  a  similar  case  in 
which  he  in  vain  attemj)ted  to  induce  abortion  by  the  sound  in  a  case 
of  contracted  pelvis;  and  Duncan  has  mentioned  an  instance  in  which 
an  intra-uterine  stem  pessary  Avas  unwittingly  introduced  and  worn  for 
some  time  by  a  jiregnaut  woman  without  any  bad  effect.  The  fact  that 
pregnancy  is  with  difficulty  interfered  Avitli  when  there  is  a  healthy  re- 
lation between  tlie  ovum  and  the  uterus  no  doubt  explains  the  disastrous 
effects  of  criminal  abortion  which  have  been  especially  insisted  on  by 
many  of  our  American  brethren. 

]\Iorl)id  states  of  the  uterus  have  an  imj)ortaut  influence  in  the  ])ro- 
duction  oFaForfiom"  Any  condition  Avhich  mechanically  interferes  with 
the  proper  development  of  the  uterus  is  apt  to  operate  in  this  way. 
Amongst  these  may  be  mentioned  fibr(iid_iuniors;  the  jiresence  of  old 
peritoneal  adhesions,  rendering  the  womb  a  more  or  less  fixed  organ; 
but,  above  all,  flexion  and  displacement  of  the  uterus.  Ketroflexion  of 
the  uterus  is  unquestionably  one  of  the  most  frequent  factors  in  its 
production,  not  only  on  account  of  the  irritation  which  the  abnormal 
position  sets  n\),  but  from  interference  with  the  uterine  circulation, 
wliich  leads  to  the  effusion  of  blood  and  the  death  of  the  ovum.  An 
inflamed  condition  of  the  cervical  and  uterine  mucous  membranes 
will  act  in  the  same  way  should  pregnancy  have  occurred,  although 
such  a  condition  more  often  prevents  conception  taking  place. 

Symptoms. — One  of  the  earliest  indications  of  imjiending  abortion 
is  more  or  less  hemorrhage.  This  may  at  first  be  slight,  and  may  last 
for  a  short  time  oidy,  recurring  after  an  interval  of  time,  or  it  may 
commence  with  a  sudden  and  ])rofuse  discharge.  Occasionally  it  is  very 
abundant,  and  its  continuance  and  amount  form  one  of  the  gravest 
.•symptoms  of  the  accident.  After  the  lo.ss  of  blood  has  contiijucd  for  a 
greater  or  less  length  of  time — it  may  be  even  for  some  days — uterine 
<'ontractions  come  on,  recurring  at  regular  intervals,  and  eventually 
lead   to  the  expulsion  of  the  ovum.     More  rarely  the  impending  mis- 


ABORTION  AND  PREMATURE   LABOR.  253 

cari'iagc   commences  with  pains,  wliicli   lead    to    laceration  of   vessels 
and  hemorrhage. 

As  long  as  one  or  other  of  these  symptoms  exists  alone  we  may  hope 
to  avert  the  threatened  miscarriao;e ;  bnt  when  both  occur  together  there 
is  little  or  no  chance  of  its  being  arrested.  (Certain  premonitory  symp- 
toms  are  described  by  authors  as  common  in  abortion,  such  as  feverish- 
ness,  shivering,  a  sensation  of  coldness;  all  of  which  are  obscure  and 
unreliable,  and  are  certainly  much  more  frequently  absent  than  ])resent]^ 

If  the  pregnancy  be  early  it  is  probable  that  the  entire  ovum  \\'ili 
shed  with  little  trouble,  and  it  often  passes  unperceived  in  the  clots 
which  surround  it.  It  is  therefore  of  importance  that  all  the  discharges 
should  be  very  carefully  examined.  After  the  second  month  the  rigid 
and  undilated  cervix  presents  a  formidable  obstacle  to  the  escape  of  the 
ovum,  and  it  may  be  a  considerable  time  before  there  is  sufficient  dila- 
tation to  admit  of  its  passage.  This  is  gradually  effected  by  the  con- 
tinuance of  pains,  but  not  without  a  severe  loss  of  blood.  It  may  be 
that  the  amnion  is  ruptured  and  the  foetus  expelled  first.  After  a 
lapse  of  time  the  secundines  are  also  shed,  but  there  may  be  a  con- 
siderable delay,  amounting  even  to  days,  before  this  is  effected.  As  long 
as  any  portions  of  the  membranes  are  retained  in  utero  the  patient  is  nec- 
essarily subjected  to  considerable  risk,  not  only  from  the  continuance  of 
hemorrhage,  but  also  from  septicaemia.  Hence  it  may  be  laid  down  as 
a  rule  that  we  can  never  consider  our  patient  out  of  danger  until  we 
have  satisfied  ourselves  that  the  whole  of  the  uterine  contents  have  been 
expelled. 

Treatment. — Our  first  endeavor  in  any  case  of  impending  miscar- 
riage will  be,  of  course,  to  avert  the  threatened  accident.  Ilf  hemor- 
rhage has  not  been  excessive,  and  if,  on  vaginal  examination — which 
should  always  be  practised — we  find  no  dilatation  of  the  os,  we  may 
entertain  a  reasonable  hope  of  success,  jilf,  on  the  contrary,  we  find  the 
OS  beginning  to  open,  if  we  are  able  to  insert  the  finger  through  it  so  as 
to  touch  the  ovum,  especially  if  pains  also  exist,  we  are  justified  in  con- 
sidering abortion  to  be  inevitable,  and  the  indication  will  then  be  to  have 
the  ovum  expelled  and  the  case  terminated  as  soon  as  possible,\  In  the 
former  case  the  most  absolute  rest  is  the  first  thing  to  insist  on.  The 
patient  should  be  placed  in  bed,  not  overburdened  with  clothes,  in 
a  cool  temperature,  and  she  should  have  a  light  and  easily  assimi- 
lated diet.  All  movements,  even  rising  out  of  bed  to  empty  the 
bladder  or  bowels,  should  be  absolutely  prohibited.  To  avert  the 
tendency  to  the  commencement  of  uterine  contraction  there  is  no 
remedy  so  useful  as  opium,  which  must  be  given  freely  and  frequently 
repeated.  It  may  be  administered  either  in  the  form  of  laudanum 
or  of  Battley's  sedative  solution,  which  has  the  advantage  of  produ- 
cing less  general  disturbance.  It  may  be  advantageously  exhibited  in 
doses  of  from  20  to  30  minims,  and  repeated  after  a  few  hours,  A 
still  better  preparation  is  chlprodyne,  which  I  have  found  of  ex- 
treme value  in  arresting  impending  miscarriage,  in  doses  of  10 
minims,  repeated  every  third  or  fourth  hour.  (If  from  any  other 
cause  it  is  considered  unadvisable  to  give  the  sedative  by  the  mouth, 
it  may  be  administered  in  a  small  starch  enema  per  rectum.     In  all 


254  f'nj'y.XAXCY. 

ctisc'S  it  w  ill  !)<•  ii('c('^;s;irv  to  kccj)  the  juiticnl  more  nr  less  iiiitlci"  the 
iiiHuence  nt'  tlif  drug  ittr  sevcnil  days  and  until  all  syniptnius  of 
niiscaiTJagv  have  passed  away.  iTTlii^  <)i)iate  ti'i'atuK'Ut  is  souictiuios 
luarvellously  etticiunt  iu  arresting  an  active  premature  labor  if  used 
early  and  persevered  hi.)  A  young  multipara  belonging  to  a  ])lithisieal 
familv  unee  came  under' my  care  in  labor  at  four  and  a  half  mouths,  the 
uterine  contractions  coming  on  at  regidar  intervals,  accompimied  by  pains 
and  a  considerable  loss  of  blood.  Under  the  use  of  rc])eatcd  doses  of 
.suli)hate  of  morj)hia  her  labor-pains  Aveakencd,  and  at  the  end  oi"  ten 
hours  ceased  entirely,  not  to  return  until  the  full  period  of  gestation  was 
accomplished,  Avlieu  I  delivered  her  of  a  living  female  child  of  small 
size,  "which  survived  several  months.  In  another  ease  labor  was 
checked  at  eight  months  and  the  foetus  delivered  at  the  full  peri(xl. 
— Ed.]  Care  should  be  taken  that  the  bowels  do  not  become  locked 
up  by  the  action  of  the  opiates — as  this  might  of  itself  be  a  cause  of 
irritation — aud  their  constipating  effects  ought  to  be  obviated  by  small 
doses  of  castor  oil  or  other  gentle  aperient.  N'^arious  subsidiary  methods 
of  treatment  have  been  recommended,  such  as  bleeding  from  the  arm  or 
the  local  application  of  leeches  iu  supposed  plethoric  states  of  the  sys- 
tem; revulsives,  such  as  dry  cupping  to  the  loins;  the  application  of  uv. 
to  check  hemorrhage;  astringents,  such  as  acetate  of  lead  <ir  galli<;  acid, 
for  the  same  purpose.  Most  of  these,  if  not  hurtful,  Avill  be  at  least 
useless.  The  cases  in  which  venesection  Avould  be  beneficial  are  ex- 
tremely rare,  and  the  local  applications,  especially  cold,  are  much 
more  apt  to  favor  than  to  prevent  uterine  action. 
f  In  cases  of  repeated  miscarriage  iu  su<-cessive  pregnancies  a  special 
cOyurse  of  prophylactic  treatmeut  is  indicated,  aud  is  often  attended  with 
much  succe&\.  In  cases  of  this  kind  the  first  indication,  and  one  which 
ought  to  be  carefully  attended  to,  is  to  seek  for  and,  if  possible,  to 
remove  or  mitigate  the  cause  which  has  given  rise  to  the  former  abor- 
tions. Those  causes  which  depend  on  constitutional  states  must  first  l)e 
carefully  investigated,  aud  ti'cated  according  to  the  indications  present. 
These  may  be  obscure  and  not  easily  discovered  ;  but  it  is  certaiidy 
unwise  to  assume  too  readily  the  existence  of  what  has  been  called  "  a 
hal)it  of  abortion,"  which  further  inquiry  may  prove  to  be  only  an 
indication  of  constitutional  debility,  degeneracy  of  the  placental  struc- 
tures, or  a  latent  and  unsuspected  syj)hilitic  taint.  If  constitutional 
debility  be  present  to  a  marked  extent,  a  generous  diet  and  a  restorative 
course  of  treatment  (])reparations  of  iron,  quinine,  and  other  suitable 
tonics)  may  effect  the  desired  object. 

[The  fluid  extract  of  Viburmim  prunifqlivm  is  believed  by  many 
American  obstetricians  to  be  of  value  in  cases  where  there  has  become 
develojH'd  a  hal)it  of  aborting  without  any  apparent  cause.  A  change 
of  ivsidence  to  a  mountainous  region  for  several  months  once  broke  u]) 
the  habit  iu  one  of  my  ])atients  (who  was  asthmatic  and  rheumatic)  after 
six  abortions  in  the  second  month,  and  the  child  saved  has  now  grown 
up.  The  mother  was  of  very  full  habit,  and  l)oth  depletive  and  opiate 
treatments  had  signally  failed. — Ed.] 

liocal  congestion  of  the  uterus  or  a  general  plethoric  state  of  the 
patient  has  often  been  su[)posed  to  be  an  efficient  cause  of  recurring 


ABORTION  AND   PREMATrilE  LABOR.  255 

abDi'tiuii.  Dr.  Ilciiiy  Ik'iuict  has  espetiiully  dwelt  on  the  influence  of 
congestion  and  abrasions  of  the  cervix  in  causing  premature  expulsion 
of  the  f(otus/  and  recioinniends  tlu;  to))ical  application  of  nitrate  of  silver 
or  other  caustic  to  the  inflanuiiatory  abrasions  existing  on  the  neck  of 
the  womb,  h^ormerly  venesc(;tion  was  a  favorite  remedy  ;  and  many 
authors  have  reconimeuded  the  local  abstraction  of  blood  by  l(!echcs 
applied  to  the  groin  or  round  the  anus,  or  even  to  the  cervix.  The 
influence  of  general  plethora  is  more  than  doubtful ;  and,  although  local 
congestions  are  })robably  much  more  cflPective  causes,  still,  it  would  seem 
more  judicious  to  treat  them  by  rest  and  local  sedatives  rather  than  by 
topical  applications,  which,  injudiciously  ap[)lied,  might  produce  the 
very  accident  they  were  intended  to  prevent. 

The  position  of  the  uterus  should  be  carefully  investigated.  If  it  be 
found  to  be  retroflexed,  a  well-fitting  Hodge's  pessary  should  be 
applied,  so  as  to  support  it  until  it  has  completely  risen  out  of  the 
pelvis. 

The  possibility  of  syphilitic  infection  should  always  be  inquired  into, 
for  this  poison  may  act  on  the  product  of  conception  long  after  all  appre- 
ciable traces  of  it  have  disappeared  from  the  infected  parent.  Should 
there  be  recurrent  abortions  in  a  patient  who  had  formerly  suffered  from 
syphilis  or  whose  husband  had  at  any  time  contracted  the  disease,  no 
time  should  be  lost  in  using  appropriate  antisyphilitic  remedies,  which 
should  invariably  be  administered  both  to  the  husband  and  wife.  Diday 
especially  insists  that  in  such  cases  it  is  not  sufficient  to  submit  the 
father  and  mother  to  a  mercurial  course  in  the  absence  of  pregnancy, 
but  that,  as  each  successive  impregnation  occurs,  the  mother  should 
ugain  commence  antisyphilitic  treatment,  even  though  she  has  no  visible 
traces  of  the  disease.^  In  this  way  there  is  reasonable  ground  for  hoping 
that  infection  of  the  ovum  may  be  prevented.  I  think,  too,  that  we 
may  be  the  more  encouraged  to  persevere  in  the  treatment  of  these 
unfortunate  cases  from  the  fact  that  the  syphilitic  poison  tends  to  wear 
itself  out.  I  have  seen  several  cases  in  which  this  taint  at  first  pro- 
duced early  abortion,  then  each  successive  pregnancy  was  of  longer 
duration,  until  eventually  a  living  child  was  born. 

In  fatty  degeneration  of  the  chorion  villi  and  in  other  morbid  states 
of  the  placenta,  which  act  by  preventing  the  proper  nutrition  of  the 
ftietus  and  the  due  aeration  of  its  blood,  there  is  no  reliable  means  of 
treatment  except  the  general  improvement  of  the  mother's  health. 
Simpson  strongly  recommended  the  administration  of  chlorate  of^potash 
in  cases  in  which  the  child  habitually  dies  in  the  latter  months  of  preg- 
nancy, on  the  supposition  that  it  supplied  to  the  blood  a  large  amount 
of  oxygen,  and  thus  made  up  for  any  deficiency  in  the  supply  of  that 
element  through  the  placental  tufts.  The  theory  is,  at  best,  a  doubtful 
one,  although  I  believe  the  drug  to  be  unquestionably  beneficial  in  cases 
of  the  kind.  It  probably  acts  by  its  tonic  properties  rather  than  in  the 
manner  Simpson  supposed.  It  may  be  given  in  doses  of  15  to  20 
grains  three  times  a  day,  and  may  be  advantageously  combined  Mith 
small  doses    of    dilute   hydrochloric   acid.      In    frequently-recurring 

'  On  Inflainmation  of  the  Uterus,  p.  432. 

2  Diday,  hifnntih'  Syphilis,  Sijd.  Soc.  Trans.,  p.  207. 


2o6  PRiyiSA  xcr. 

pwnvMurv  lahors  with  dciitl  cliildi-cii  Siiiipsnii  stronnly  rccoiiiniciidod 
tlic  induction  of  premature  labor  a  little  helore  tlie  time  at  \vlii<li  we  iia<l 
reason  to^l)elie\'e  that  the  fo'tns  had  nsnally  perished;  oi",  in  (»ther 
words,  iK'I'ore  the  placental  disease  had  advanced  snilieiently  far  t(j  inter- 
fore  with  its  nutrition.  The  practice  has  constantly  been  adopted  witii 
success,  and  is  perfectly  le<;itimate,  but  the  difficulty,  of  course,  is  to  fix 
on  tlie  right  time.  Careful  auscultation  of  the  lu'tal  heart  may  be  of 
some  use  in  guiding  us  to  a  decision,  as  the  death  of  the  f(etus  is  gener- 
ally preceded  for  some  days  by  irregular,  tumidtuous,  and  intermittent 
action  of  the  heart. 

!  There  will  always  remain  a  certain  number  oi'  cases  in  which  no 
appreciable  cause  can  be  discovered.  |  Under  such  circumstances  pro- 
longed rest,  at  least  until  the  time  has  passed  atwdiich  abortion  formerly 
took  place,  will  afford  the  best  chance  of  avoiding  a  recui-rence  of  the 
accident.  There  nuist  always  be  some  difficulty  in  can-ying  out  this 
indication,  inasmuch  as  the  patient's  health  is  aj)!  to  suffer  in  other  ways 
from  the  confinement  and  the  want  of  fresh  air  and  exercise  which  it 
entails.  The  strictness  with  w'hich  rest  should  be  insisted  on  must  vary 
in  different  cases,  but  it  should  be  specially  attended  to  at  what  would 
have  been  the  menstrual  periods,  At  these  times  the  patient  should 
remain  in  bed  altogether ;  at  others  she  may  lie  on  a  sofa,  and,  if 
circumstances  permit,  spend  part  of  the  day  at  least  in  the  open  air. 
Sexual  intercourse  should  be  prohibited.  Should  actual  symptoms  of 
abortion  come  on,  the  preventive  treatment,  already  indicated,  may  be 
resorted  to.  Great  care,  however,  should  be  used  in  ]irescribing  opiates 
as  preventives,  and  they  should  be  given  for  a  specified  time  only.  I 
have  seen  more  than  once  an  incurable  habit  of  opium-eating  originate 
from  the  incautious  and  too  long-continued  exhibition  of  the  drug  in 
such  cases. 

When  we  have  satisfied  ourselves  that  abortion  is  inevitable,  we 
must  proceed  to  employ  treatment  that  fiivors  the  expulsion  of  the 
ovum. 

If  the  OS  be  sufficiently  dilated  and  the  pains  strong,  we  may  lind  the 
ovum  sc])aratcd  and  protruding  from  the  os.  AVe  may  then  be  able  to 
detach  it  by  the  finger.  For  this  purpose  the  uterus  is  dej)rcsscd  from 
without  by  the  left  hand,  w'hile  an  endeavor  is  made  to  scoop  out  the 
ovum  with  the  examining  finger.  If  it  be  out  of  reach,  and  yet  appear 
detached,  chloroform  should  be  administered,  the  whole  hand  introduced 
into  the  vagina  and  the  finger  into  the  uterine  cavity.  The  com})lete 
detachment  oi'  the  ovum  can  in  this  way  be  far  moiv  readily  and  safely 
effected  than  by  using  any  of  the  many  ovum-foi-cej)s  which  have  been 
invented  for  the  ])urpose. 
/^  If  the  ovum  be  not  sufficiently  separated  oi-  the  os  be  undilated, 
I  means  must  be  taken  to  control  the  hemorrhage  until  the  former  can  be 
Vremovcd  or  ex])elled.  It  is  here  that  plugging  of  the  vagina  finds  its 
rnost  useful  a|)plication.  This  may  be  done  in  various  ways.  That  most 
usually  employed  is  filling  the  vagina  with  a  tolerably  large  sponge,  in 
the  intei-stices  of  which  the  blood  coagulates.  A  better  j)lan  is  to  soak 
a  number  of  pledgets  of  cotton-wool  in  carbolized  water  and  tie  a  string 
round  each.     The  vagina  can  be  completely  and  effectively  packed  with 


ABORTION  AND  PREMATURE  LABOR.  257 

these;  luitl  this  is  Ixwt  dune  thr()Uji;li  a  si)eeuhini,  or,  better  still,  with 
the  aid  of  a  duck-bill  spe(!ulum,  the  patient  being  placed  on  her  left 
side.  Each  j)ledti;et  should  be  covered  with  <rlycerin,  which  eom])letely 
prevents  the  olfensive  odor  which  otherwise  always  arises.  The  pledgets 
can  be  removed  by  traction  on  the  strings,  but  if  these  are  not  used 
much  pain  is  caused  in  getting  th(!m  out  of  the  vagina.  The  plug 
should  never  be  left  in  for  more  than  six  or  eight  hours,  after  which  a 
fresh  one  may  be  inserted  if  necessary.  Two  or  three  full  doses  of  the 
li(piid  extract  of  ergot,  of  .5ss  to  3j  each,  or  a  subcutaneous  injection  of 
ergotine,  may  be  given  while  the  plug  is  in  position.  The  plug  itself  is 
a  strong  excitant  of  uterine  action,  and  the  two  combined  often  effect 
complete  detachment,  so  that  on  the  removal  of  the  tampon  the  ovum 
may  be  found  lying  loose  in  the  os  uteri.  If  the  os  be  undilated 
and  the  ovum  entirely  out  of  reach,  the  former  may  be  opened  by 
means  of  sponge  or  laminaria  tents.  I  think  a  well-prepared  sponge 
tent  the  most  eifectual,  and  it  can  be  maintained  in  situ  by  a  vagi- 
nal plug  below  it.  It  also  acts  as  a  most  efficient  plug,  effectually 
controlling  all  hemorrhage.  In  a  few  hours  it  opens  up  the  os  suf- 
ficiently to  admit  the  finger. 

(The  most  troublesome  cases  are  those  in  which  the  foetus  is  first 
expelled  and  the  placenta  and  membranes  remain  in  utero.j  As  long 
as  this  is  the  case  the  patient  can  never  be  considered  safe  from  the 
occurrence  of  septicaemia.  Dr.  Priestley  has  strongly  insisted  on  the 
importance  of  removing  the  secundines  as  soon  as  possible.  There 
can  be  no  doubt  that  this  should  be  done  whenever  it  is  feasible. 
Cases,  however,  are  frequently  met  with  in  which  any  forcible  attempt 
at  removal  would  be  likely  to  prove  very  hurtful,  and  in  which  it 
is  better  practice  to  control  hemorrhage  by  the  plug  or  sponge  tent, 
and  wait  until  the  placenta  is  detached,  which  it  will  generally  be 
in  a  day  or  two  at  most.  Under  such  circumstances  fetor  and  decom- 
position of  the  secundines  may  be  prevented  by  intra-uterine  injections 
of  diluted  Condy's  fluid.  Provided  the  os  be  sufficiently  patulous 
to  prevent  the  collection  of  the  fluid  in  the  uterine  cavity,  and  not 
more  than  a  drachm  or  two  of  the  fluid  injected  at  a  time,  so  as 
simply  to  wash  away  and  disinfect  decomposing  detritus,  they  can  be 
used  with  perfect  safety.  Sometimes  cases  are  met  Avith  in  which 
the  OS  has  entirely  closed,  and  in  which  we  can  only  suspect  the 
retention  of  the  placenta  by  the  history  of  the  case,  the  continuance 
of  hemorrhage,  or  the  presence  of  a  fetid  discharge.  Should  we  see 
reason  to  suspect  this,  the  os  must  be  dilated  with  sponge  or  lami- 
naria tents,  and  the  uterine  cavity  thoroughly  explored  under  chloro- 
form. This  condition  of  things  is  far  from  uncommon  in  Avomen 
who  have  not  had  medical  assistance  from  the  first,  and  it  often 
gives  rise  to  very  troublesome  and  anxious  symptoms.  It  has  been 
said  that  placentse  thus  retained  have  been  completely  absorbed,  and 
cases  of  the  kind  have  been  related  by  Naegele  and  Osiander.  The 
spontaneous  absorption,  however,  of  so  highly  organized  a  body  as 
the  placenta  would  be  a  phenomenon  of  the  most  remarkable  cha- 
racter; and  it  seems  more  natural  to  suppose  that  in  most  cases  of 
the  kind  the  placenta  has  been  cast  off  -without  the  knowledge  of 
17 


258  pnicGyAycY. 

the  paliciit.  Suinetiincs  the  placenta  never  lioeonies  entirely  detached, 
and,  retaining;  oruanic  connection  Nvitii  the  uterine  walls,  Inrnis  what 
has  been  called  a  "  placental  [)()lyjtus."  This  may  j)i<Klu<e  sec(»ndary 
hemoiTha«ie  in  the  same  way  lis  an  ordinary  HI)i'oid  polyjms.  Barnes 
recommends  the  removal  of  these  ma-sses  by  means  of  a  wire  ecra- 
sour.     Before  their  detection  the  os  uteri  nuist  be  opened  up. 

Retention  in  utcro  of  a  Blighted  Ovum. — I'lic  cases  ])re\i(jusly 
alluded  to,  in  which  an  ovimi  has  perished  in  early  prejrnancy  and 
is  retained  //;  utcro,  are  often  puzzling  and  may  give  rise  to  serious 
nioral  and  medico- legal  cpiestions.  The  blighted  ovum  n)ay  be  retained 
for  many  months,  the  outside  limit,  according  to  McClintock,'  by 
whom  the  subject  has  been  ably  discussed,  being  nine  months.  The 
a}»pearanee  of  the  ovum  when  thrown  off  will  give  no  reliable  clue 
to  the  length  of  time  which  has  ela})sed  since  it  ])erished.  The  symp- 
toms are  often  very  obscure.  Generally  there  have  been  the  usual 
indications  of  pregnancy,  which,  with  or  without  signs  of  impending 
miscarriage,  disappear  or  are  modified,  and  then  follows  a  period  of 
ill-health,  Avith  pelvic  uneasiness  and  irregular  metrorrhagia,  which 
may  be  mistaken  for  menstruation.  Occasionally,  but  by  no  means 
necessarily,  there  is  a  fetid  discharge,  and  this  probably  exists  only 
Avhen  the  membranes  have  broken  and  air  has  access  to  the  ovum. 
In  some  cases  obscure  septica?mic  symptoms  have  been  oljserved.  Such 
symptoms  are  obviously  too  indefinite  to  lead  to  an  accurate  diagno- 
sis. In  the  course  of  time  the  ovum  is  generally  thrown  oft',  with 
more  or  less  hemorrhage.  If  the  nature  of  the  case  is  detected, 
ergot  may  be  given  to  promote  the  expulsion  of  the  uterine  contents, 
and  it  mav  even  be  advisable  to  dilate  the  cervix  with  sponge  or 
laminaria  tents  and  remove  them  artificially. 

Subsequent  Manag-ement  of  Abortion. — The  frequency  with 
which  abortion  leads  to  chronic  uterine  di.sease  should  lead  us  to  attach 
much  more  irajwrtance  to  the  sub.secpient  management  of  the  patient 
than  has  been  cu.stomary.  The  u.«ual  ])ractice  is  to  confine  the  patient 
to  bed  for  two  or  three  days  only,  and  then  to  allow  her  to  resume 
her  ordinary  avocations,  on  the  supposition  that  a  miscarriage  requires 
less  subsequent  care  than  a  confinement.  The  contrary  of  this  is, 
however,  most  probably  the  ca.se,  for  the  uterus  has  been  emptied 
when  it  is  unprepared  for  involution,  and  that  process  is  often  very 
imperfectly  performed.  We  should  therefore  insi.st  on  at  least  as  much 
attention  being  paid  to  rest  as  after  labor  at  term. 

'  Sydenham  Society's  edition  of  Smcllie's  Midwifery,  vol.  i.  p.  169. 


PART  III. 

LABOR. 


CHAPTER   I. 

THE  PHENOMENA  OF  LABOE. 

Delivery  at  Term. — In  considering  delivery  at  term  we  have  to 
discuss  two  distinct  classes  of  events. 

(  One  of  these  is  the  series  of  vital  actions  brought  into  play  in  order 
to  effect  the  expulsion  of  the  child  \  and  the  other  consists  of  the  move- 
ments imparted  to  the  child,  the  body  to  be  expelled  >j  in  other  words, 
the  mechanism  of  delivery. 

Causes  of  Labor. — Before  proceeding  to  the  consideration  of  these 
important  topics  a  few  words  may  be  said  as  to  the  determining  causes 
of  labor.  This  subject  has  been  from  the  earliest  times  a  qucestio  ve.v- 
ata  among  physiologists,  and  many  and  various  are  the  theories  which 
have  been  broached  to  explain  the  curious  fact  that  labor  spontaneously 
commences,  if  not  at  a  fixed  epoch,  at  any  rate  approximately  so.  It 
must  be  admitted  that  even  yet  there  is  no  explanation  which  can 
be  implicitly  accepted. 

The  explanations  which  have  been  given  may  be  divided  into  two 
classes :  those  which  attribute  the  advent  of  labor  to  the  foetus,  and  j 
those  which   refer   it   to   some   change   connected  with  the  maternal  1 
generative  organs. 

The  former  is  the  opinion  which  was  held  by  the  older  accoucheurs, 
who  assigned  to  the  foetus  some  active  influence  in  efl'ecting  its  own 
expulsion.  It  need  hardly  be  said  that  such  fanciful  views  have  no 
kind  of  physiological  basis.  Others  have  supposed  that  there  might 
be  some  change  in  the  placental  circulation  or  in  the  vascular  sys- 
tem of  the  foetus  which  might  solve  the  mystery. 

/The  majority  of  obstetricians,  however,  refer  the  advent  of  labor  to  [( 
purely  maternal  causes.)  Among  the  more  favorite  theories  is  one  which 
was  originally  started  in  this  country  [/.  e.  England]  by  Dr.  Power,  and 
adopted  and  illustrated  by  Depaul,  Dubois,  and  other  Avriters.  It  is 
based  on  the  assumption  that  there  is  a  sphincter  action  of  the  fibres 
of  the  cervix,  analogous  to  that  of  the  sphincters  of  the  bladder  and 
rectum,  and  that  when  the  cervix  is  taken  up  into  the  general  uterine 
cavity  as  pregnancy  advances,  the  ovum  presses  upon  it,  irritates  its 
nerves,  and  so  sets  up  reflex  action,  which  ends  in  the  establishment  of 

259 


260  LABOR. 

uterine  rontraetion.  This  theory  \v:is  founded  on  erroneous  ooneept ions 
of  the  chanties  that  oceurn'd  in  tlie  neck  of  the  uterus;  and,  as  it  is 
certain  that  ol)lit('ralion  ol'  tlic  cervix  docs  not  really  take  phice  in  the 
manner  that  l*o\ver  believed  ^vhen  liis  theory  was  broached,  it  is  obvious 
that  its  supposed  result  cannot  follow.  A  modification  of  this  theory  is 
that  held  by  Stoltz  and  Bandl.  /  According  to  this  view,  when  the  cer- 
vix softens  duriuii;  the  last  two  weeks  of  pregnancy  the  ])ainless  uterine 
contractions  of  gestation  act  upon  the  os  internum,  and  open  it  suffi- 
ciently to  admit  of  the  ovum  pressing  on  the  lower  segment  of  the 
uterus,  aiid  so  inducing  labor. 

(  Exti'eme  distension  of  the  uterus  has  been  held  to  be  the  determining 
cause  of  labor — a  view  lately  revived  by  Dr.  King  of  Washington,' 
who  believes  that  contractions  are  induced  because  the  uterus  ceases  to 
augment  in  capacity,  while  its  contents  still  continue  to  increase.  This 
hypothesis  is  sufficiently  disproved  by  a  number  of  clinical  fiicts  whi<-h 
show  that  the  uterus  may  be  subject  to  excessive  and  even  rapid  disten- 
sion— as  in  cases  of  hydramnios,  multiple  pregnancy,  and  hydatidifbrm 
degeneration  of  the  ovum — without  the  supervention  of  uterine  contrac- 
tions. \ 

I  Another  inciter  of  uterine  action  has  been  supposed  to  be  the  separa- 
tion of  the  ovum  from  its  connections  to  the  uterine  parietes,  in  conse- 
quence of  fatty  degeneration  of  the  decidua  occurring  at  the  end  of 
pregnancy.  The  supposed  result  of  this  change,  which  undoubtedly 
occurs,  is  that  the  ovum  becomes  so  detached  from  its  organic  adhesions 
as  to  be  somewhat  in  the  position  of  a  foreign  body,  and  thus  incites  the 
nerves  so  largely  distributed  over  the  interior  of  the  uterus.      This 

(theory,  which  has  been  widely  accepted,  was  originally  started  by  Sir 
James  Y.  Sim])son,  who  pointed  out  that  some  of  the  most  efficient 
means  of  inducing  labor  (such,  for  example,  as  the  insertion  of  a  gum- 
*  elastic  catheter  between  the  ovum  and  the  uterine  walls)  jwobably  act  in 
the  same  way — viz.  by  effecting  separation  of  the  membranes  and 
detachment  of  the  ovum. 

Barnes  instances,  in  o])position  to  this  idea,  the  fact  that  ineffectual 
attempts  at  labor  come  on  at  the  natural  term  of  gestation  in  cases  of 
extra-uterine  pregnancy,  when  the  foetus  is  altogether  independent  of 
the  uterus,  and  therefore,  he  argues,  the  cause  cannot  be  situated  in  the 
uterus  itself.  A  fair  answer  to  this  argument  would  be  that  although, 
in  such  cases,  the  Momb  does  not  contain  the  ovum,  it  does  contain  a 
decidua,  the  degeneration  and  sejiaration  of  which  might  suffice  to  in- 
duce the  abortive  and  partial  attempts  at  lal)or  then  witnessed. 

LeopokP  suggests  that  the  advent  of  labor  may  be  connected  with 
other  changes  in  the  decidua  M'hich  occur  in  advanced  ]iregnaucv.  He 
]ioints  out  that  then  giant-cells,  containing  many  nuclei,  appear  in  the 
serotina  which  penetrate  the  uterine  sinuses,  and  cause  the  formation  in 
them  of  thrombi.  The  obstruction  in  the  calil)re  of  a  number  of  these 
vessels  leads  to  a  stasis  of  the  maternal  blood  returning  from  the  ]>la- 
eonta,  and  to  an  increase  of  carbonic  acid  in  it,  which  may  excite  the 
motor  centre  for  uterine  contraction. 

^  Amerirmi  JnurnnI  of  Obslclrirs,  1S70-71,  vol.  iii.  p.  561. 

^".Studien  iiber  die  Schleimbaut,"  etc.,  Arch.  f.  Gyn.,  1877,  Bd.  xi.  S.  443. 


Til?:  PHENOMENA    OF  LABOR.  201 

Objections  to  these  Theories. — A  serious  objection  to  all  tlitse 
theories — wliieli  are  l)ase(l  on  the  assnni])tion  tiiat  some  local  irrita- 
tion brings  on  contraction — is  the  fact  which  has  not  been  generally 
appreciated,  that  uterine  contractions  ixvci^  al^i:il;y■s  present  during  preg- 
nancy as  a  normal  occurrence,  and  that  they  may  be,  and  often  are, 
readily  intensified  at  any  time  so  as  to  result  in  j)reraature  deKvery. 

It  is  indeed  most  likely  that  at  or  about  the  full  term  the  nervous 
supply  of  the  uterus  is  so  highly  developed,  and  in  so  advanced  a  state 
of  irritability,  that  it  more  readily  responds  to  stimuli  than  at  other 
times.  If  by  separation  of  the  decidua  or  in  some  other  ^vay  stimula- 
tion of  the  excitor  nerves  is  then  effected,  more  frequent  and  forcible 
contractions  than  usual  may  result,  and,  as  they  become  stronger  and 
more  regular,  terminate  in  labor.  But,  allowing  this,  it  still  remains 
quite  unexplained  why  this  should  occur  with  such  regularity  at  a  def- 
inite time. 

Tyler  Smith  tried,  indeed,  to  prove  that  labor  came  on  naturally 
at  what  would  have  been  a  menstrual  epoch,  the  congestion  attending 
the  menstrual  nisus  acting  as  the  exciter  of  uterine  contraction.  He 
therefore  refers  the  onset  of  labor  to  ovarian,  rather  than  to  uterine, 
causes.  Although  this  view  is  upheld  with  all  its  author's  great  talent, 
there  are  several  objections  to  it  difficult  to  overcome.  Thus,  it  assumes 
that  the  pieriodic  changes  in  the  ovary  continue  during  pregnancy,  of 
which  there  is  no  proof.  Indeed,  there  is  good  reason  to  believe  that 
ovulation  is  suspended  during  gestation,  and  with  it,  of  course,  the 
menstrual  nisus.  Besides,  as  has  been  well  objected  by  Cazeaux, 
even  if  this  theory  were  admitted,  it  would  still  leave  the  mystery 
unsolved,  for  it  would  not  explain  why  the  menstrual  nisus  should 
act  iu  this  way  at  the  tenth  menstrual  epoch  rather  than  at  the 
ninth  or  eleventh. 

In  spite,  then,  of  many  theories  at  our  disposal,  it  is  to  be  feared 
that  we  must  admit  ourselves  to  be  still  in  entire  ignorance  of  the  reason] 
Avhy  labor  should  come  on  at  a  fixed  epoch. 

Mode  in  which  the  Expulsion  of  the  Child  is  Effected. — The 
expulsion  of  the  child  is  effected  by  thefcou tractions  of  the  muscular 
fibres  of  the  uterus)  aided  by  those  of  some  of  the  abdominal  miiscles. 
These  efforts  are  in  the  main  entirely  independent  of  volition.  So  far 
as  regards  the  uterine  contractions,  this  is  absolutely  true,  for  the  mother 
has  no  power  of  originating,  lessening,  or  increasing  the  action  of  the 
uterus.  As  regards  the  abdominal  muscles,  however,  the  mother  is 
certainly  able  to  bring  them  into  action,  and  to  increase  their  power  by 
voluntary  efforts ;  but,  as  labor  advances  and  the  head  passes  into  the 
vagina  and  irritates  the  nerves  supplying  it,  the  abdominal  muscles  are 
often  stimulated  to  contract,  through  the  influence  of  reflex  action,  inde- 
pendently of  volition  on  the  part  of  the  mother. 

(There  can  be  little  doubt  that  the  chief  agent  in  the  expulsion  of  the 
child  is  the  contraction  of  the  uterus  itself.)  This  opinion  is  almost 
unanimously  held  by  accoucheurs,  and  the  influence  of  the  abdominal 
muscles  is  believed  to  be  purely  accessory.     Dr.  Haughtou/  however, 

'  "On  the  Muscular  Forces  employed  in  Parturition,"  etc.,  Dublin  Quart.  Journ.  Med. 
Sc,  1870,  vol.  xlix.  p.  459. 


2()2  LABOR. 

iniiiiilains  a  view  wliicli  is  directly  contrarv  to  this.  From  an  cxaiiii- 
iiation  of"  the  lorce  of"  the  uteiiiic  contractions,  arrived  at  hy  nieasnring 
the  anionnt  of  nuiseiUar  fibre  contained  in  the  \valls  of  tlie  uterus,  lie 
arrives  at  the  conclusion  that  the  uterine  contractions  are  chiefly  in- 
Huential  in  rupturing  the  membranes  and  dilating  the  os  uteri,  bringing 
into  action,  if  needful,  a  force  e(juivalent  to  54  ])Ounds;  but  when  this 
is  cllcctcd,  and  the  second  stage  of"  labor  has  coinnienced,  he  thinks  the 
remainder  of  the  labor  is  mainly  completed  by  the  conti'actions  of  the 
alxloininal  nuiscles,  to  which  he  attributes  enoriuous  ])o\vers,  equivalent, 
il"  netdfui,  to  a  pressure  of  523.65  jxiunds  on  the  area  of  the  jx-lvic 
canal. 

These  views  bear  on  a  topic  of  ])rinuiry  consequence  in  the  ])hysi- 
ology  of  labor.  They  have  been  fully  criticised  l)v  Duncan,  who  has 
devoted  much  ex])eriinental  research  to  the  study  of  the  powers  brought 
into  action  in  the  expulsion  of  the  child.  His  conclusions  are  that,  so 
far  from  the  enormous  force  being  employed  that  Ilaughton  estimated, 
in  the  large  majority  of  cases  the  effective  force  brought  to  bear  on  the 
child  by  tlie  combined  action  of  both  the  uterine  and  abdriminal  mus- 
cles is  less  than  uL!4)onmls — that  is,  less  than  the  force  which  Ilaughton 
attributed  to  the  uterus  alone.  In  extremely  severe  labors,  when  the 
resistance  is  excessive,  he  thinks  that  extra  power  may  be  em])loyed; 
but  he  estimates  the  maximum  as  not  above  80  ])ounds,  including  in 
this  total  the  action  of  both  the  uterine  and  abdominal  muscles.  Joulin 
arrived  at  the  conclusion  that  the  uterine  contractions  were  capable  of 
resisting  a  maximum  force  of  about  one  hundredweight.  Both  these 
estimates,  it  will  be  observed,  are  much  under  that  of  Ilaughton,  which 
Duncan  describes  as  representing  "a  strain  to  which  the  maternal 
machinery  could  not  be  subjected  without  instantaneous  and  utter 
destruction." 

f  There  are  many  facts  in  the  history  of  parturition  which  make  it 
'certain  that  the  chief  factor  in  the  expulsion  of  the  child  is  the  uteru-y 
Among  these  mav  be  mentioned  occasional  cases  in  which  thPfirtTon  of 
the  abdominal  muscles  is  materially  lessened,  if  not  annulled — as  in 
])rofound  antesthesia  and  in  some  cases  of  para])legia — in  which, 
nevertheless,  uterine  contractions  suffice  to  effect  delivery.  The  most 
familiar  example  of  its  influence,  however,  and  one  that  is  a  matter  of 
everv-day  observation  in  ])ractice,  is  when  inertia  of  the  uterus  exists. 
In  such  cases  no  eilbrt  on  the  ])art  of  the  mother,  no  amount  of  vi»lun- 
tary  action  that  slu;  can  bring  to  bear  on  the  child,  has  any  apjn'cciable 
influence  on  the  progress  of  the  labor,  which  remains  in  abeyance  until 
the  defective  uterine  action  is  re-established  or  until  artificial  aid  is 
given. 

The  contraction  of  the  uterus,  then,  l)eing  the  main  agent  in  deliveiy, 
it  is  important  for  us  to  appreciate  its  mode  of  action  and  its  eflect  on 
the  ovum. 

Uterine  Contractions  at  the  Commencement  of  Labor. — We 
have  seen  that  intermittent  and  generally  paiidess  uterine  contractions 
exist  during  pregnancy.  As  the  period  for  delivery  approaches  these, 
become  more  fre(jncnt  and  intense,  until  labor  actually  commences, 
when  they  begin  to  be  sufficiently  developed  to  effect  the  opening  up 


THE  PHENOMENA    OF  LABOR.  203 

of  the  OS  uteri  witli  a  view  to  the  passage  of  the  child.  They  are  now 
accompauied  by  pain,  wliieh  increases  as  labor  advances,  and  is  so  cha- 
racteristic that  "pains"  are  universally  used  as  a  descriptive  term  for 
the  contractions  tlieinselves.  It  does  not  necessarily  follow  that  uterine 
contractions  are  painless  unless  they  connnence  to  effect  dilatation  of 
the  OS  uteri.  On  the  contrary,  during  the  last  days  or  even  -weeks  of 
pregnancy  women  constantly  have  irregular  contractions,  accompanied 
by  severe  suffering,  which,  however,  pass  off"  without  producing  any 
marked  effect  on  the  cervix.  When  labor  has  actually  begun,  if  the 
hand  is  placed  on  the  uterus  when  a  ]>ain  commences,  the  contraction 
of  its  muscular  tissue  is  very  apparent,  and  the  Avhole  organ  is  observed 
to  become  tense  and  hard,  the  rigidity  increasing  until  the  pain  has 
reached  its  acme,  the  uterine  walls  then  relaxing,  and  remaining  soft 
until  the  next  pain  comes  on.  (At  the  commencement  of  labor  these} 
pains  are  few,  separated  from  each  other  by  a  considerable  interval,  and 
of  short  duration.  In  a  perfectly  tyj^ical  labor  the  interval  between 
the  pains  becomes  shorter  and  shorter,  while  at  the  same  time  the  dura- 
tion of  each  pain  is  increased.  At  first  they  may  occur  only  once  in 
an  hour  or  more,  while  eventually  there  may  not  be  more  than  a 
few  minutes'  interval  between  them^ 

If,  when  the  pains  are  fairly  established,  a  vaginal  examination  be 
made,  the  os  uteri  will  be  found  to  be  thinned  and  dilated  in  propor- 
tion to  the  progress  of  the  labor.     During  the  contraction  the  bag  of 
membranes  will  be  felt  to  bulge,  to  become  tense  from  the  downward 
pressure  of  the  liquor  amnii  within  it,  and  to  protrude  through  the  os 
if  it  be  sufficiently  open.  /The  membranes,  with  the  contained  liquor 
amnii,  thus  form  a  fluid  wedge,  which  ha^  a  most  important  influence 
in  dilating  the  os  uteri  (see  Frontispiece).;  (This  does  not,  however,  form  \  ( 
the  sole  mechanism  by  which  the  os  uteri  is  dilated,  for  it  is  also  acted  |  ) 
upon  by  the  contractions  of  the  muscular  fibres  of  the  uterus,  which  }/ 
tend  to  pull  it  open.^  It  is  probable  that  the  muscular  dilatation  of  the  •' 
OS  is  effected  chiefly  Ify  the  longitudinal  fibres,  which  as  tliey  shorten  act 
upon  the  os  uteri,  the  part  where  there  is  least  resistance. 

Partly,  then,  by  muscular  contraction,  partly  by  mechanical  pressure, 
the  cervical  canal  is  dilated,  and  as  it  opens  up  it  becomes  thinner  and 
thinner  until  it  is  entirely  taken  up  into  the  uterine  cavity. 

There  is  no  longer  any  obstacle  to  the  passage  of  the  presenting  part  , 
of  the  child  into  the  cavity  of  the  pelvis,  and  the  force  of  the  pains  I 
now  generally  effects  the  rupture  of  the  membranes  and  the  escape  of  / 
the  liquor  amnii.     There  is  often  observed  at  this  time  a  temporarv 
relaxation   in   the   frequency   of  the  pains,   Avhich   had   been   steadily 
increasing;  but  they  soon  recommence  v/ith  increased  vigor.     If  the 
abdomen  be  now  examined,  it  will  be  observed  to  be  nuich  diminished 
in  size,  partly  in  consequence  of  the  escape  of  the  liquor  amnii,  partly 
from  the  descent  of  the  fcetus  into  the  pelvic  cavity. 

(The  character  of  the  pains  soon  changes.  They  become  stronger, 
longer  in  duration,  separated  l)y  a  shorter  interval,  and  accompanied  l)y 
a  distinct  forcing  efibrt,  being  generally  described  as  "the  bearing-down  " 
pains,  j  Now  is  the  time  at  which  the  accessory  muscles  of  jxirturition 
come  into  operation)     The  patient  brings  them  into  play  in  the  manner 


■2(ii  LABOR. 

which  will  he  siil)>('(|iK'ntly  (lc'sciil>0(l,  and  tho  comhincd  aotion  of  the 
uterine  and  aluloniinal  nuiseles  continues  until  the  expulsion  of  the 
child  is  cllccte<l. 

The  ])iecise  mode  of  uterine  contraction  is  still  somewhat  a  matter 
of  dispute.  It  is  generally  descrihed  as  commencing  in  the  cervix, 
j)assing  gradually  upward  by  jK'ristaltie  action,  tiie  wave  then  return- 
iuir  downward  toward  the  os  uteri.  This  view  was  maintained  by 
A\'i<rand.  and  has  been  inilorsed  by  Rigby,  Tyler  Smith,  and  many 
other  writers.  In  snpi)ort  of  it  they  instance  the  fact  that  on  the  acces- 
sion of  a  pain  the  presenting  ])art  first  recedes,  the  bag  of  membranes 
then  becomes  tense  and  protrudes  through  the  os,  and  it  is  not  until 
some  time  that  the  presenting  part  of  the  child  itself  is  pushed  down. 
(it  is  very  doubtful  if  this  view  is  correct  jTand  a  careful  examination 
lof  the  course  of  the  pains  would  rather  leacl  to  the  belief  that  the  con- 
tractions QLimmence  at  the  fundus,  where  the  muscular  tissue  is  most 
largely  developed,  and  gradually  proceetl  downward  to  the  cervix  ;  the 
waves  of  contraction  being,  however,  so  rapid  that  the  whole  organ 
seems  to  harden  en  masse^  (The  apparent  recession  of  the  presenting 
part  and  the  bulging  of  tue\ag  of  memiijaSes' are  certainly  no  proof 
that  the  contractions  begin  at  thg.j8erCTx;  for  the  commencing  contrac- 
tion would  necessarily  paeh-tlown  the  fluid  in  front  of  the  head,  and 
cause  the  membranes  to  bulge  and  the  os  to  l)ecome  tense,  before  its  force 
was  brought  to  bear  on  the  fcetiis  itself.^  Indeed,  did  the  contraction 
commence  at  the  lower  part  of  the  uterus,  we  should  expect  the  o])posite 
of  what  takes  place  to  occur,  and  the  waters  to  be  pushed  ujJAvard  and 
awav  from  the  cervix.  The  fundal  origin  of  the  contraction  is  further 
illustrated  bv  what  is  observed  when  the  hand  of  the  accoucheur  is 
placed  in  the  uterine  cavity,  as  often  happens  in  certain  cases  of  hemor- 
rhage or  turning;  for  if  a  pain  then  comes  on  it  will  be  felt  to  start  at 
the  fundus,  and  gradually  compress  the  hand  from  above  downward. 

Value  of  the  Intermittent  Character  of  the  Pains. — The  inter- 
mittent character  of  the  contractions  is  of  great  practical  im])ortance. 
AVere  they  continuous,  not  r)nly  wonld  Vhe   mnscnlnr   powers   of  the 
patient,  bp  rnpidly  cvh.niis^crf -jltuf  by  tlie  ol)literation  of  the  vessels  pro- 
duced by  the  muscular  contraction  the  circulation  throutrh  the  ])lacenta 
would  be  interfered  with  and  the  life  of  the  child  imperilled.'j    Hence  I 
one  of  the  chief  dangers  of  protracted  laljor,  esjx'cially  after  tlie  es«ij)ej 
of  the  liquor  amnii,  is  that  the  uterine  fibres  may  enter  into  a  state  of  i 
tonic  rigidity — a  condition  that  cannot  be  long  continued  without  serious 
risks  both  to  the  mother  and  child. 

(Tlie  fact  that  the  uterine  contractions  are  altogether  involuntary 
proves  them  to  be  excitetl — as  indeed  we  would  a  priori  infer  from  our 
knowledge  of  the  anatomicid  arrangement  of  the  nerves  of  the  uterus — 
solely  by  the  sympathetic  system.  Still,  it  is  a  fiict  of  everv-day  obser- 
vation that  they  can  be  largely  influenced  by  emotions)  Various  stin)uli 
applie<l  to  the  s|)inal  system  (»f  nerves  (as,  for  example,  when  the  mam- 
mse  are  irritated)  have  also  a  marked  eflect  in  inducing  uterine  contrac- 
tion. The  precise  mode  in  which  such  influence  is  conveyed  to  the 
uterus,  in  spite  of  the  various  experiments  which  have  been  made  for 
the  ])urpose  of  determining  how  i'ar  labor  is  aflected  by  destruction  of 


THE  PHENOMENA    OF  LABOR.  2G5 

the  s])iiial  cord,  is  still  a  matter  of"  doubt.  After  the  f(etus  has  passed 
thrmiiih  the  cervix,  the  spinal  nerves  distributed  to  the  va<rina  and 
])erineuni  are  excited  by  the  pressure  of  the  presenting  l)art,  and 
through  them  the  accessory  powers  of  j^arturition  are  chiefly  brought 
into  play.  The  contraction  of  the  muscles  of  the  vagina  itself  is  sup- 
posed to  have  some  influence  in  favoring  the  expulsion  of  the  ffjctus 
after  the  birth  of  j)art  of  the  body,  and  also  in  promoting  the  expulsion 
of  the  placenta.  lu  the  lower  animals  the  vagina  has  a  very  marked 
contractile  property,  and  is,  in  some  of  them,  the  main  agent  by  which 
the  young  are  expelled.  In  the  human  subject  this  influence  is  certainly 
of  very  secondary  importance. 

Character  and  Source  of  Pains  during"  Labor. — :The  amount  of 
suffering  experienced  during  labor  varies  much  in  different  cases,  and  is 
in  direct  proportion  to  the  nervous  susceptibility  of  the  patient.  There 
are  some  women  -who  go  through  laiDor  with  little  or  no  pain  at  all. 
This  is  proved  by  the  cases  (of  which  there  are  numerous  authentic 
instances  recorded)  in  which  labor  has  commenced  during  sleep,  and 
the  child  has  been  actually  born  without  the  mother  awaking.  I  am 
acquainted  with  a  lady  who  has  had  a  large  family  who  assures  me  that, 
though  labor  is  accompanied  by  a  sense  of  pressure  and  discomfort,  she 
experiences  nothing  which  can  be  called  actual  pain.  Such  a  happy 
state  of  affairs  is,  however,  extremely  exceptional,  and  in  the  vast 
majority  of  cases  parturition  is  accompanied  by  intense  suffering  during 
its  whole  course,  in  some  cases  amounting  to  anguish  which  has  proba- 
bly no  parallel  under  any  other  condition. 

The  precise  cause  of  the  pain  has  been  much  discussed,  and  is  no 
doubt  complex.  ^  .^ 

(In  the  early  stage  of  labor,  and  before  the  dilatation  of  the  os,  it  is  "  •■  > 
chiefly  seated  in  the  back,  from  whence  it  shoots  round  the  loins  and 
down  the  thighsT  It  is  then  probably  produced  partly  by  pressure  on 
the  nerve-filaments  caused  by  contraction  of  the  muscular  fibres  to 
which  they  are  distributed,  and  partly  by  stretching  and  dilatation  of 
the  muscular  tissue  of  the  cervix.  ^I.  Beau  believes  that  in  this  stage 
the  pain  is  not  produced,  strictly  speaking,  in  the  uterus  itself,  but  is 
rather  a  neuralgia  of  the  lumbo-abdominal  nerves.  The  pains  at  this 
time  are  generally  described  as  "  acute  "  and  "  grinding" — terms  which 
sufficiently  well  express  their  nature.  In  highly  nervous  women  these 
pains  are  often  much  less  well  borne  than  those  of  a  later  stage,  and  the 
suffering  they  undergo  is  indicated  by  their  extreme  restlessness  and 
loud  cries  as  each  contraction  supervenes. 

As  the  OS  dilates  and  the  labor  advances  into  the  expulsive  stage  other 
sources  of  suffering  are  added.  The  presenting  part  now  passes  into  the 
vagina  and  presses  on  th^  vaginal  nerves,  as  well  as  on  the  large  ner- 
vous plexuses  lying  in  the  pelvis.  As  it  descends  lower  it  stretches  the 
perineum  and  yul>"a,  and  presses  on  the  bladder  and  rectum.  Hence 
cramps  are  produced  in  the  muscles  supplied  by  the  nerve-plexuses,  as 
well  as  an  intolerable  sense  of  tearing  and  stretching  in  the  vulva  and 
])erineum,  and  often  a  distressing  feeling  of  tenesmus  in  the  bowels. 
By  this  time  the  accessory  muscles  of  parturition  are  brought  into  action, 
and  they,  as  well  as  the  uterine  nuiscles,  are  thrown  into  frequent  and 


266  LABOR. 

violent  contractions,  which,  independently  of  the  other  causes  mentioned, 
are  sufficient  of  themselves  to  ))r(Mluce  f^reat  pain,  likened  to  that  of 
colic,  produced  by  involuntary  and  rcpeatetl  contraction  of  the  muscles 
of  the   intestines. 

Takinu-  all  these  causes  into  consideration,  there  is  no  lack  of  sufficient 
cxplanatiiin  of  the  intoli'ral)le  suflering  which  is  so  constant  an  accom- 
paniment ot"  childbirth. 

Effect  of  the  Pains  on  the  Mother  and  Foetus. — The  effect  of  the 
pains  on  the  mother's  circulation  is  well  marked.  ^Fhe  rapidity  of  the 
j)ulse  increases  distinctly  with  each  contraction,  and  as  the  jiain  [)asses 
ofrTFagaiTrdc'Tliic-  u>  \i<  forinci'  -i.iti'.  A  >iinilar  observation  has  been 
made  Avith  repaid  tn  the  sounils  i.t'  ihe  tirial  heart,  esjiecially  alter  the 
expulsion  of  the  liquor  amnii.  )  Hicks  has  pointed  out  that  during  a  pain 
the  muscular  vibrations  give  rise  to  a  sound  which  often  resembles  that 
of  the  foetal  heart,  and  which  completely  disappears  when  the  muscular 
tissue  relaxes.  The  effect  of  the  pain  in  intensifying  the  uterine  souffle 
has  been  already  mentioned.  The  strong  muscular  efforts  would  natu- 
rally lead  us  to  expect  a  marked  elevation  of  temjierature  during  laboi-. 
Further  observations  on  this  point  are  required  ;  but  Squire  asserts  that 
there  is  generally  only  a  very  slight  increase  in  temperature  during 
delivery,  rapidly  passing  off  as  soon  as  labor  is  over. 

Division  of  Labor  into   Stages. — Such   being    the   jihysiological 
|r  facts  in  connection  with  laljor-pains,  we  may  now  describe  the  ordinary 
n  progress  of  a  natural  labor — that  is,  one  terminated  by  the  natural  pow- 
ers and  with  a  head  presenting. 

For  facility  of  description  obstetricians  have  long  been  in  the  habit 
of  dividing  the  course  of  labor  into  sfar/es,  which  correspond  pretty  accu- 
rately Avith  the  natural  sequence  of  events.     For  this  purpose  we  gen- 
erally talk  of  thi'ee  stages:  viz.  (1)  from  the  commencement  of  regular 
pf   pains  until  the  complete  dilatation  of  the  cervix  (star/e  of  effacement  (Did 
\   dilatation) ;   (2)  from  the  complete  dilatation  of  the  cervix  until  the 
I    expulsion  of  the  child  {stage  of  expulsion) ;  (3)  the  concluding  stage, 
I    comprising  the  permanent  contraction  of  the  uterus  and  the  se])aration 
\    and  expulsion  of  the   placenta  {xt<(fje  of  the  aftcr-birtJt).     To  these  we 
e    may   conveniently  add  a  preparatory  stage,  antecedent  to  the  regular 
commencement  of  the  labor. 

Preparatory  Stage. — For  a  short  time  before  delivery,  varying 
from  a  few  days  to  a  week  or  two,  certain  premonitory  symptoms  gen- 
erally exist  which  indicate  the  ap])roacliing  advent  of  labor.  Sometimes 
they  are  well  marked  and  cannot  be  mistaken  ;  at  others  they  are  so 
slight  as  to  escape  observation.  (Amongst  the  most  connnon  is  a  sink- 
iinr  of  the  ntcriis  into  the  pelvic  cavitv]  resulting  from  the  relaxation  of 
the  soft  parts  preceding  delivery.\  Tlie  result  is  that  the  upj)er  edge  of 
the  uterine  tumor  is  less  high  than  l)efore,  and  in  consequence  the  j)res- 
sure  on  the  respiratory  organs  is  diminished,  and  the  woman  often  feels 
lighter  and  altogether  less  unwieldy  than  in  the  ])revious  weeks.  If  a 
vaginal  examination  be  made  at  this  time,  the  lower  segment  of  the 
utei'us  will  be  found  to  have  sunk  lower  into  the  pelvic  cavity ;  and  the 
consequence  of  this  is  that,  while  the  respiration  is  less  embarrassed  and 
the  patient  feels  less  bulky,  other  accompaniments  of  pregnancy,  such 


THE  PHENOMENA    OF  LABOR.  267 

as  heiuOTrhoids,  irriUibilily  of  the  bladder  and  bowels,  and  redeiiia  of 
the  limbs,  become  aggravated.  The  increased  jjressure  on  the  bowels 
often  induces  a  sort  of  temporary  diarrhoea,  which  is  so  far  advantageous 
that  it  empties  the  bowels  of  feces  which  may  have  collected  within 
them.  As  has  already  been  pointed  out,  the  contractions  which  have 
been  going  on  at  intervals  during  the  latter  months  of  pregnancy  now 
get  more  and  more  marked,  and  they  have  the  effect  of  i)roducing  a  real 
shortening  of  the  cervix,  which  is  of  great  value  i)reparatory  to  its  dila- 
tation. ^More  marked  mucous  discharjj'e  from  the  cavity  of  the  cervix 
also  generally  occurs  a  sliort  tmie  betore  labor,  ana  it  is  not  unfrequeutly 
tinged  with  blood  from  the  laceration  of  minute  capillary  vessels.  This 
discharge,  popularly  known  as  the  "  shows,"  is  a  pretty  sure  sign  that 
labor  is  not  far  off.  It  may,  however,  be  entirely  absent,  even  until  the 
birth  of  the  child.  When  copious,  it  serves  to  lubricate  the  passages, 
^nd  is  generally  coincident  with  rapid  dilatation  of  the  parts  and  a 
speedy  labor. 

During  this  time  (^premonitory  stage)  painful  uterine  contractions  are 
often  present,  which,  however,  have  no  effect  in  dilating  the  cervix.  In 
some  cases  they  are  frequent  and  severe,  and  are  very  apt  to  be  mistaken 
for  the  commencement  of  real  labor.  Such  "/sisfi-Ji^y -s/'  as  they  are 
termed,  are  often  excited  and  kept  up  by  local  irritations,  such  as  a 
loaded  or  disordered  state  of  the  intestinal  canal ;  and  they  frequently 
give  rise  to  considerable  distress  and  much  inconvenience  both  to  the 
])atient  and  practitioner.  They  are,  it  should  be  remembered,  only  the 
normal  contractions  of  the  uterus,  intensified  and  accompanied  with 
pain. 

First  Stage,  or  Dilatation. — As  labor  actually  commences  the 
uterine  contractions  become  stronger,  and  the  fact  that  they  are  "  true  " 
pains  can  be  ascertained  by  their  effect  on  the  cervix,  (if  a  vaginal 
examination  be  made  during  one  of  these,  the  membranes  will  be  felt  to 
become  tense  and  bulging  during  the  paiu.  and  the  os  uteri  will  be  found 
partially  dilated  and  thinned  at  its  edges.  I  As  labor  advances  this  effect 
on  the  OS  becomes  more  and  more  marked.  At  first  the  dilatation  is  very 
slight,  perhaps  uot  more  than  enough  to  admit  the  tip  of  the  examining 
finger,  and  both  the  upper  and  lower  orifices  of  the  cervix  can  be  made 
out.  As  the  pains  get  stronger  and  more  frequent,  dilatation  proceeds 
in  the  way  already  described  and  the  cervix  gets  more  thin  and  tense, 
until  we  can  feel  a  thin  circular  ring  (which  is  lax  between  the  pains, 
but  becomes  rigid  and  tense  during  the  contraction  when  the  bag  of 
waters  bulges  through  it)  without  any  distinction  between  the  upper  and 
lower  orifices.  During  this  time  the  patient,  although  she  may  be  suf- 
fering acutely,  is  generally  able  to  sit  up  and  walk  about.  The  amount 
of  pain  experienced  varies  much  according  to  the  character  of  i:he 
patient.  In  emotional  women  of  highly- developed  nervous  susceptibili- 
ties it  is  generally  very  great.  They  are  restless,  irritable,  and  despond- 
ing, and  when  the  pain  conies  oiucrv  out  loudly.  fThe  character  of  the 
cry  is  peculiar  and  well  marked  during  the  first  stage,  and  has  constantly 
been  described  by  obstetric  writers  as  characteristic.  It  is  acute  and 
high,  and  is  certainly  very  different  from  the  deep  iri-oans  of  the  second 
stage,  when  the  breath  is  involuntarily  retainetTto  assisf  the  parturient 


2G8  LABOR. 

eilbrt.]  Wlii'ii  dilatation  is  nearly  coinjjli'tt'd  various  reflex  nervous  plie- 
uoniena  olten  show  themselves.  One  of"  these  is  uausea  and  voniitinir; 
another  is  uneontrollablc  shiyerinj^,  which  is  not  acconipanietl  by  a 
sense  of  euldness,  the  i)atient  beinu'  ol'teii  hot  and  j)ersj)irin<r.  Jiotli 
these  symptoms  indicate  that  the  |)i'(»|)nlsiv('  stat>e  will  shoi-tly  com- 
menee  ;  and  tiiey  may  be  i-cnardcd  ;is  l'avt)ra!>le  rather  than  otherwise, 
although  they  aiv  a])t  to  alarm  the  })atient  and  her  friends.  Jiy  this 
time  the  os  is  fully  dilated,  the  membranes  jjenerally  rui)tnre  sponta- 
neously, and  a  considerable  portion  of  the  liquor  amnii  flows  away. 
The  head,  if  presenting,  often  acts  as  a  sort  of  ball-valve,  and,  falling 
<lown  on  the  ajierturc  of  the  cervix,  prevents  the  comjilete  evacuation 
of  the  licpior  anmii,  which  escapes  by  degrees  during  the  rest  of  the 
labor,  or  may  be  retained  in  considerable  quantity  until  (he  birth  of  the 
child. 

It  not  unfrequeutly  happens,  if  the  membranes  are  somewhat  tougher 
than  usual  and  the  pains  frequent  and  strong,  that  the  foetus  is  ]nished 
through  the  pelvis,  and  even  ex})ellcd  surrounded  by  the  membranes. 
AVhen  this  occurs  the  child  is  said  to  be  born  with  a  "  caal,"  and  this 
event  would  doubtless  ha[)pen  more  frequently  than  it  does  were  it  not 
the  custom  of  the  accoucheur  to  rupture  the  membranes  artificially  as 
soon  as  the  os  is  completely  opened  up,  after  which  time  their  integrity 
is  no  longer  of  any  value. 

The  OS  is  now  entirely  retracted  over  the  ])rcsenting  jiart,  and  is  no 
longer  to  be  felt,  the  vagina  and  the  uterine  cavity  forming  a  single 
canal.  Xow^  the  mucous  discharge  is  generally  abundant,  so  that  the 
examining  finger  brings  away  long  strings  of  glairy,  transi)arent  inucus 
tinged  with  blood.  The  pains,  after  a  short  interval  of  rest,  become 
entirely  altered  in  character.  The  uterus  contracts  tightly  round  the 
foetus,  the  presenting  part  descends  into  the  pelvis,  and  the  true  propul- 
sive pains  commence.  The  accessory  muscles  of  jiarturition  now  come 
into  play.  AVith  each  pain  the  patient  takes  a  deep  inspiration,  and 
thus  fills  the  chest  so  as  to  give  a  j)oint  d\tj)imi  to  the  abdominal 
muscles.  For  the  same  reason  she  involuntarily  seizes  hold  of  some 
point  of  support,  as  the  hand  of  a  bystander  or  a  towel  tied  to  the  bed, 
and  at  the  same  time  pushes  with  her  feet  against  the  end  of  the  bed, 
and  so  is  able  to  bear  down  to  advantage.  The  cries  are  no  longer 
sharp  and  loud,  but  consist  of  a  series  of  deep  suppressed  groans,  which 
corres])ond  to  a  succession  of  short  expirations  made  during  the  strain- 
ing ettbrt.  In  this  way  the  abdominal  muscles  contract  forcibly  on  the 
uterus,  which  they  further  stimulate  to  action  by  pressing  upon  it.  It 
is  to  be  observed  that  these  strainin<£  efl'orts  are,  to  a  considerable  extent, 
under  the  control  of  the  patient,  l^y  encouraging  her  to  hold  her  bi'catli 
and  bear  down  they  can  be  intensified,  while  if  we  wish  to  lessen  thciii 
we  can  advise  her  to  call  out,  and  when  she  does  so  the  abdominal 
muscles  have  no  longer  a  fixed  point  of  action.  Although  the  i)atienl 
may  thus  lessen  the  effect  of  these  accessory  muscles,  it  is  entirely  out 
of  her  power  to  stoj)  their  action  altogether.  As  labor  advances  the 
head  descends  lower  and  lower,  receding  somewhat  in  the  intervals 
between  the  i)ains,  tmtil  eventually  it  conies  down  on  the  perineum, 
which  it  soon  distends. 


I 


THE  PHENOMENA    OF  LABOR.  269 

'Ilie  j)ains  now  get  stronger  and  more  frequent,  often  with  scareely  a 
perce])til)Ie  interval  between  tliem,  until  the  perineum  gets  stretched  by 
tiie  advan(ung  head.  In  the  interval  between  the  pains  the  elasticity 
of  the  perineal  structures  pushes  the  head  upward  so  as  to  diminish  the 
tension  to  which  the  }K'rineuin  is  subjected,  the  next  pain  again  putting 
it  on  the  stretch  and  protruding  the  head  a  little  farther  than  before. 
By  this  alternate  advance  and  recession  the  gradual  yielding  of  the 
structures  is  favored  and  risk  of  laceration  greatly  diminished.  During 
this  time  the  pressure  of  the  head  mechanically  empties  the  boM'cl  of  • 
its  contents.  During  the  last  pains,  when  the  perineum  is  stretched  to 
the  utmost,  the  anal  aperture  is  dilated,  sometimes  to  the  size  of  a  [sil- 
ver dollar]  ;  and  in  this  way  the  jDerineum  is  relaxed,  just  as  the  dis- 
tension, and  consequent  risk  of  laceration,  are  at  their  maximum.  The 
apex  of  the  head  now  protrudes  more  and  more  through  the  vulva, 
surrounded  by  the  orifice  of  the  vagina,  and  eventually  it  glides  over 
the  perineum  and  is  expelled.  The  intensity  of  the  suffering  at  this 
moment  generally  causes  the  patient  to  call  out  loudly.  The  force  of 
the  abdominal  muscles  is  thus  lessened  at  the  last  moment,  and  this,  in 
combination  with  the  relaxation  of  the  sphincter  ani,  forms  an  admira- 
ble contrivance  for  lessening  the  risk  of  perineal  injury.  The  rest  of 
the  body  is  generally  expelled  immediately  by  a  single  pain,  and  with 
it  are  discharged  the  remains  of  the  liquor  amnii  and  some  blood-clots 
from  se])aration  of  the  placenta;  and  so  the  second  stage  of  labor 
terminates. 

The  Third  Stage. — The  third  stage  commences  after  the  expulsion 
of  the  child.  It  is  of  paramount  importance  to  the  safety  of  the 
mother  that  it  should  be  conducted  in  a  natural  and  efficient  manner ; 
for  it  is  now  that  the  uterine  sinuses  are  closed,  and  the  frail  barrier  by 
which  nature  effects  this  may  be  very  readily  interfered  with,  and  seri- 
ous and  even  fatal  loss  of  blood  ensue.  Unfortunately,  it  is  too  often 
the  case  that  the  practitioner's  entire  attention  is  fixed  on  the  expulsion 
of  the  child,  so  that  the  natural  history  of  the  rest  of  delivery  is  very 
generally  imperfectly  studied  and  understood. 

As  soon  as  the  child  is  expelled  the  uterine  fibres  contract  in  all 
directions,  and  the  hand,  following  the  uterus  down,  \vill  find  that  it 
forms  a  firm  rounded  mass  lying  in  the  lower  part  of  the  abdominal 
cavity.  By  retraction  of  its  internal  surface  the  placental  attachments, 
which  probal)ly  remain  undisturbed  until  the  expulsion  of  the  child, 
are  generally  separated,  and  the  after-birth  remains  in  the  cavity  of  the 
uterus  as  a  foreign  body. 

(The  escajie  of  blood  from  the  open  mouths  of  the  uterine  sinuses  is 
now  prevented  in  two  ways:  viz.  (1)  by  the  contractions  of  the  uterine 
walls ;  and  the  more  firm,  persistent,  and  tonic  this  is  the  more  certain 
is  the  immunity  from  hemorrhage ;  (2)  by  the  formation  of  coagula  in 
the  mouths  of  the  vessels.^  Xny  undue  haste  in  ])romoting  the  expul- 
sion of  the  placenta  tends  to  prevent  the  latter  of  these  two  luemostatic 
safeguards,  and  is  apt  to  be  followed  by  loss  of  blood.  After  a  certain 
time,  averaging  from  a  quarter  to  half  an  hour,  the  uterus  will  be  felt 
to  harden,  and,  if  the  case  be  solely  left  to  nature,  what  has  been  aptly 
called  a  miniature  labor  occurs.     Pains  come  on,  and  the  placenta  is 


270 


/..I  noR. 


Fiff.  98. 


si)()nt;inp()iisly  oxpollcd  from  (Ik"  uterus,  cither  iuto  the  canal  of  the 
vajiiua  or  even  externally.  In  most  obstetric  works  it  is  stated  that  the 
aiter-hirth  may  he  sej)arate(l  eitjjer  Irom  its  centre  or  e(l<i:e,  and  that  it 
is  very  generally  expelled  through  the  os  in  an  inverted  form,  with  its 
fa^tal  surface  downward,  and  folded  transvci'sely  on  itself.  That  this  is 
the  mode  in  which  the  j)lacenta  is  often  expelled  when  traction  on  the 
coril  is  practised  is  a  matter  of  certainty.  It  then  passes  thntuuh  thcos 
vei'v  much  in  the  shape  of  an  inverted  umhrclla.  It  is  certain,  how- 
ever, that  this  is  not  the  natural  mechanism  of  its  <lelivery.  /The  sul>- 
ject  has  been  well  studied  by  Berry  Hart,'  who  Iuls  shown  that  during 
the  contractions  of  the  third  stage  of  labor  the  })lacenta  is  "thrown  into 
heights  and  hollows,"  and,  if  the  case  be  left  entirely  to  nature,  it 
descends  with  its  edge  or  a  })oint  near  its  edge  first, 
its  uterine  and" detached  surface  gliding  along  the 
inner  surface  of  the  uterus,  the  foldings  of  its 
structure  being  parallel  to  the  long  diameter  of  the 
uterine  cavity  (Fig.  98).  \Iu  this  way  it  is  expelled 
into  the  vagina,  and  during  the  process  little  or  no 
hemorrhage  occurs.  When  the  ])lacenta  is  dra\\n 
out  iu  the  wa}'  too  generally  ])ractised,  it  obstructs 
the  aperture  of  the  os,  and,  acting  like  the  piston 
of  a  pump,  tends  to  promote  hemorrhage.  The 
corollaries  as  to  treatment  drawn  from  these  facts 
will  be  subsequently  considered.  I  am  anxious, 
however,  here  to  direct  attention  to  nature's  meeh- 
anism,  because  I  believe  there  is  no  ])art  of  labcir 
about  the  management  of  which  erroneous  views 
are  more  prevalent  than  that  of  this  stage,  and 
none  in  which  they  are  more  apt  to  lead  to  serious 
Mode  in  which  the  pia-  cousequeuces;  and  unless  the  mode  in  which  Nature 
pX^d.^'A^tcrDuncaii')  ^'^^^'^^  ^^^^  cxpulsiou  of  the  ])lacenta  and  ])revents 
hemorrhage  is  thoroughly  understood,  we  shall  cer- 
tainly fail  in  assisting  her  in  a  proper  manner.  In  the  large  i)ropor- 
tion  of  cases,  when  left  entirely  to  themselves,  the  placenta  would  be 
retained,  if  not  in  the  uterus,  at  any  rate  in  the  vagina,  for  a  consider- 
able time — possibly  for  several  liours;  and  such  delay  would  very 
unnecessarily  tire  the  ])atience  of  the  ])ractitionei-  and  be  ])rejndicial 
to  the  patient.  It  is,  therefore,  our  duty  in  the  majority  of  cases  to 
promote  the  expulsion  of  the  after-birth  ;  and  when  this  is  ])ropcrly 
and  scientifically  done  we  increase  rather  than  diminish  the  patient's 
safety  and  comfort.  But  in  order  to  do  this  we  must  assist  Nature,  and 
not  act  in  op|)osition  to  her  method,  as  is  so  often  the  case. 

After-Pains. — When  once  the  ])lacenta  is  expelled  the  uterus  con- 
tracts still  moi-e  firmly,  and  in  a  tyjiical  case  is  felt  just  within  the 
pelvic  brim,  hard  and  firm,  and  about  the  size  of  a  cricket-ball,  (tcii- 
erally  for  several  liours,  or  even  for  one  or  two  days,  it  occasionally 
relaxes  and  contracts,  and  these  contractions  give  rise  to  the  "  after- 
pains"  from  which  women  often  suffer  nuich.  ^  The  object  of  these 
pains  is  no  doubt  to  ex})el  any  coagula  that  may  remain  in  the  uterus, 

'  "  Sectional  Anatomy  of  Labor,"  J^diii.  Med.  Jouni.,  Novenil)er,  1S87. 


I 


THE  PHENOMENA    OF  LABOR.  271 

and  there  fore,  liowever  unpleasant  tliey  ]nay  be  to  the  })atient,  they 
must  be  considered,  unless  very  excessive,  to  be  salutary  rather  than 
otherwise.    | 

Duration  of  Labor. — The  length  of  labor  varies  extremely  in  differ- 
ent cases,  and  it  is  quite  impossible  to  lay  down  any  definite  rules  with 
regard  to  it.  Bubject  to  exceptions,  labor  is  longer  in  priniipane  than 
in  multiparse,  on  account  of  the  greater  resistance '  oT  t Ii e  soft  parts  in 
the  former,  especially  of  the  structures  about  the  vagina  and  vulvaj 
It  is  also  generally  stated  that  the  difficulty  of  labor  increases  with  the 
age  of  the  ]>atient,  and  that  in  elderly  primiparse  it  is  likely  to  l)e 
lunisually  tedious,  from  rigidity  of  the  soft  parts.  It  is  very  doubtful 
if  this  opinion  has  any  real  basis,  and  in  such  cases  the  practitioner 
often  finds  himself  agreeably  disappointed  in  the  result.  Mr.  Roper,^ 
indeed,  argues  that  the  wasting  of  the  tissues  which  occurs  after  forty 
years  of  age  diminishes  their  resistance,  and  that  first  labors  after  that 
age  are  easier,  as  a  rule,  than  in  early  life.  The  habits  and  mode  of 
life  of  patients  have  no  doubt  a  considerable  influence  on  the  duration 
of  labor,  but  we  are  not  in  possession  of  any  very  reliable  facts  with 
regard  to  this  subject.  It  is  reasonable  to  suppose  that  the  tissues  of 
large,  muscular,  strongly-developed  women  will  offer  more  resistance 
than  those  of  slighter  build.  On  the  other  hand,  women  of  the  latter 
class,  especially  in  the  upjjer  ranks  of  life,  more  often  develop  nervous 
susceptibilities,  which  may  be  expected  to  influence  the  length  of  their 
labors.  The  average  duration  of  labor,  calculated  from  a  large  number 
of  cases,  is  from  eight  to_ ten  hours  •  even  in  primiparse,  however,  it  is 
constantly  terminated  in  one  or  two  hours  from  its  commencement,  and 
may  be  extended  to  twenty-four  hours  without  any  symptoms  of  urgency 
arising.  In  multiparre  it  is  frequently  over  in  even  a  shorter  time. 
Indications  calling  for  interference  may  arise  at  any  time  during  the 
progress  of  labor,  independently  of  its  length.  The  proportion  between 
the  length  of  the  first  and  second  stages  also  varies  considerably.  The 
first  stage  is  generally  the  longest,  and  it  is  stated  by  Cazeaux  to  be 
normally  about  twice  the  length  of  the  second.  This  is  probably  under 
the  mark,  and  I  believe  Jouliu  to  be  nearer  the  truth  in  stating  that 
the  first  stage  should  be  to  the  second  as  four  or  five  to  one,  rather  than 
as  two  to  one.  Often  when  the  first  stage  has  been  very  prolonged  the 
second  is  terminated  rapidly. 

The  practitioner  is  constantly  asked  as  to  the  probable  length  of  labor, 
and  the  uncertainty  of  this  should  always  lead  him  to  give  a  most 
guarded  opinion.  Even  when  labor  is  progressing  apparently  in  the 
most  satisfactory  manner  the  pains  frequently  die  away,  and  delivery 
may  be  delayed  for  many  hours.  In  the  first  stage  a  cervix  that  is 
apjiarently  rigid  and  unyielding  may  rapidly  and  unexpectedly  dilate, 
and  delivery  soon  follow.  In  either  case,  if  the  practitioner  has  com- 
mitted himself  to  a  positive  opinion  he  is  apt  to  incur  blame,  and  it  is 
far  better  always  to  be  extremely  cautious  in  our  predictions  on  this 
point. 

Period  of  the  Day  at  "which  Labor  Occurs A  somewhat  larger 

proportion  of  deliveries  occur  in  the  early  hours  of  the  morning  than  at 

'  Ohst.  Trans.,  1886,  vol.  vii.  p.  51. 


272  LABOR. 

other  times.  Tims.  West '  found  that  out  of  2019  deliveries,  780  took 
phioe  from  11  i'.  M.  to  7  A.  M.,  GG2  ironi  7  A.  M.  to  3  r.  M.,  and  577 
from  3  i>.  M.  to  11   I'.  M. 


CHAPTER  II. 

MECHANISM  OF   DELIVERY   IN  HEAD  PRESENTATION. 

Importance  of  the  Subject. — It  is  quite  impossible  to  over-estimate 
the  importanee  of  thorouohly  understanding  the  mechanism  of  the  pas- 
sage of  the  foetus  through  the  pelvis.  This  dominates  the  Avhole  .scien- 
tific practice  of  midwifery,  and  the  practitioner  cannot  acquire  more  than 
a  merely  empirical  knowledge,  such  as  may  be  po.sse.ssed  by  any  unedu- 
cated midwife,  or  conduct  the  more  difficult  cases  requiring  operative 
interference  with  safety  to  the  patient  or  satisfaction  to  himself,  unless 
he  thoroughly  ma-sters  the  subject. 

In  treating  of  the  physiological  phenomena  of  labor  it  was  assumed 
that  we  had  to  do  with  an  ordinary  case  of  head  presentation,  the  descrip- 
tion being  applicable,  with  slight  variation!?,  to  j^resentations  of  other 
parts  of  the  foetus.  So  in  discussing  the  mechanical  ])henomena  of 
delivery  I  shall  describe  more  in  detail  the  mechanism  of  head  presenta- 
tions, reserving  any  account  of  the  mechanism  of  other  presenta- 
tions until  they  are  separately  studied.  Head  presentation  is  so  much 
more  frequent  than  that  of  any  other  part — amounting  to  95  per  cent, 
of  all  ca.ses — that  this  mode  of  studying  the  subject  is  fully  justified  ; 
and,  when  once  the  student  has  mastered  the  ])henomena  of  delivery  in 
head  presentations  he  will  have  little  difficulty  in  understanding  the 
mechanism  of  labor  when  other  jxirts  of  the  fcetus  present,  based,  as  it 
always  is,  on  the  same  general  plan. 

Mode  of  Recognizing-  the  Position  of  the  Head  by  its  Sutures 
and  Fontanelles. — In  entering  on  this  study  we  come  to  appreciate  the 
importance  of  the  sutures  and  fontanelles  in  enabling  us  to  detect  the 
]iosition  of  the  foetal  head,  and  to  watch  its  ])rogress  through  the  jiclvis  ; 
and  unless  the  tacfns  cntditvs  by  which  these  can  be  distinguished  from 
each  other  has  been  acquired,  the  practitioner  will  be  unable  to  .«atisfy 
himself  of  tlie  exact  j^rogress  of  the  labor.  Nor  is  this  always  easy. 
Indeed,  it  requires  considerable  experience  and  practice  before  it  is  pos- 
sible to  make  out  the  position  of  the  head  with  absolute  certainty  ;  but 
tliis  knowledge  should  always  be  aimed  at,  and  the  student  will  never 
regret  the  time  and  troul)le  he  spends  in  acquiring  it. 

At  the  commencement  of  labor  the  long  diameter  of  the  head  lies  in 
almost  any  diameter  of  the  pelvic  brim,  except  in  the  antero-posterior, 
where  there  is  not  space  for  it.     In  the  large  majority  of  ca.ses,  how- 

^  Amer.  Med.  Jourii.,  1854. 


MECHANISM   OF  DELIVERY  IN  HEAD  PRESENTATION.     273 

ever,  it  enters  the  pelvis  in  one  or  other  of  tlie  oblique  diameters,  or  in 
one  between  the  oblique  and  transverse ;  but  until  it  has  fairly  passed 
through  the  brim  it  more  freciuently  lies  directly  in  the  transverse  diam- 
eter than  has  been  generally  su})i)()sed.  Hence  obstetricians  are  in  the 
habit  of  describing  the  head  as  lying  in  four  [)Ositious  according  to  the 
parts  of  the  pelvis  to  which  the  occiput  points;  the  first  and  third  posi- 
tions being  those  in  which  the  long  diameter  of  the  head  occupies  the 
right  oblique  diameter  of  the  pelvis,  the  second  and  fourth  those  in 
which  it  lies  in  the  left  oblique.  Many  subdivisions  of  these  positions 
have  been  made,  which  only  complicate  the  subject  and  render  it  more 
difficult  to  understand. 

Pour  Positions  Described. — The  positions,  then,  of  the  fcetal  head 
after  it  has  entered  tlie  brim,  which  it  is  of  importance  to  be  able  to 
distinguish  iu  practice,  are — 

First  {left  occipito-antcrior,  occipito-lceva  anterior^  O.L.A.). — The  occi- 
JDut  points  to  the  left  foramen  ovale,  the  sinciput  to  the  right  sacro-iliac 
synchondrosis,  and  the  long  diameter  of  the  head  lies  in  the  right  ob- 
lique diameter  of  the  pelvis. 

Second  (right  occipito-anterior,  occipito-dexfra  anterior^,  o.d.a.). — 
The  occiput  points  to  the  right  foramen  ovale,  the  forehead  to  the  left 
sacro-iliac  synchondrosis,  and  the  long  diameter  of  the  head  lies  iu  the 
left  oblique  diameter  of  the  pelvis. 

Third  {right  occipito-p)Osterior ,  occipito-dextra  posterior,  O.D.P.). — 
The  occiput  points  to  the  right  sacro-iliac  synchondrosis,  the  forehead  to 
the  left  forameu  ovale,  and  the  long  diameter  of  the  head  lies  in  the 
right  oblique  diameter  of  the  pelvis.  This  position  is  the  reverse  of  the 
first. 

Fourth  (left  ocoipito-posterior,  occipito-lceva  posterior,  o.l.p.). — The 
occiput  points  to  the  left  sacro-iliac  synchondrosis,  the  forehead  to  the 
right  foramen  ovale,  and  the  long  diameter  of  the  head  lies  in  the  left 
oblique  diameter  of  the  pelvis.  This  position  is  the  reverse  of  the 
second. 

The  relative  frequency  of  these  positions  has  long  been,  and  still  is, 
a  matter  of  discussion  among  obstetricians.  Accordino'  to  Naeo-ele,  to 
whose  classical  essay  we  owe  the  greater  part  of  our  knowledge  of  the 
subject,  the  head  lies  in  the  right  oblique  diameter  in  99  per  cent,  of  all 


Naegele 

Naegele,  Jr.    ... 
Simpson  and  Barry 

Dubois 

Murphy 

Swayne    


First 
Position 

(O.L.A.) 


70.00 
64.64 
7G.45 
70.83 
63.23 
86.36 


Second 
Position 

(O.D.A.) 


.29 

2.87 

16.18 

9.79 


Third 
Position 

(O.D.P.) 


29.00 
32.88 
22.68 
25.66 
16.18 
1.04 


Fourth 
Position 

(O.L.P.) 


Not 
;  Classified 


.58 

.62 

4.42 

2.8 


1.00 
2.47 


cases.  More  recent  researches  have  thrown  some  doubt  on  the  accuracy 
of  these  figures,  and  many  modern  obstetricians  believe  that  the  second 
(o.d.a.)   position,  which   Naegele   believed    only  to  be  observed  as  a 

18 


274  LA  noii. 

transitional  stao:P  iii  tlic  natural  jji-o^i-css  of  the  third  (o.d.p.)  posi- 
tion, i.s  nuu'h  more  t'onmiun  than  he  siij)j)ose(l.  Tliis  quostion  \vill  be 
more  fully  discuased  when  mo  treat  of  the  mechanism  of  occipito- 
])osterior  delivery,  and  in  the  mean  time  it  may  serve  to  show  the 
discrej)anc'y  which  exists  in  the  opinions  of  modern  writers  if  ^\e 
fnrnisii  the  ])r('ccdinji-  table  of  the  relative  i'requency  of  the  various 
positions,^  copied  from  Ijeislinuin's  work.  Here  it  will  be  seen  that 
all  ol)stetricians  are  agreed  as  to  the  immensely  greater  frequen(y  of 
tlie  Hrst  (o.L.A.)  position — the  only  point  at  issue  being  the  relative 
frequency  of  the  second  (o.d.a.)  and  third  (o.d.p.). 

A'^arious  explanations  have  been  given  of  the  greater  frequency  with 
which  the  head  lies  in  the  right  oblique  diameter.  By  some  it  is 
referred  to  the  natural  tendency  of  the  back  of  the  foetus,  as  shown  by 
the  experimental  researches  of  Honing  and  other  writers,  to  be  directed, 
in  consequence  of  gravitation,  forward  and  to  the  left  side  of  the 
mother  in  the  erect  attitude,  and  backward  and  to  her  right  side  in 
the  recumbent.  The  explanation  given  by  Simpson  was  that  the  head 
lay  in  the  right  oblique  diameter  in  consequence  of  the  measurement  of 
the  left  oblique  being  more  or  less  lessened  by  the  presence  of  the 
rectum.  When  the  rectum  is  collapsed,  indeed,  the  narrowing  of 
the  diameter  is  slight;  but  it  is  so  often  distended  by  fecal  matter — 
sometimes,  when  constijjation  exists,  to  a  very  great  extent — that  it  may 
really  have  a  very  important  influence  in  determining  the  position  of 
the  icetal  head. 

In  describing  the  mechanism  of  delivery  it  will  be  well  for  us  to  con- 
centrate our  attention  on  the  first  (o.l.a.)  or  most  common  position, 
dwelling  subsequently  more  briefly  on  the  diiferences  between  it  and 
the  less  common  ones. 

Description  of  the  First  Position. — In  this  position,  when  the  head 
commences  to  descend  the  occiput  lies  in  the  brim  pointing  to  the  left 
ileo-pectineal  eminence,  the  forehead  is  directed  to  the  right  sacro-iliac 
synchondrosis,  and  the  sagittal  suture  runs  obliquely  across  the  ])elvis  in 
the  right-oblique  diameter.  The  back  of  the  child  is  turned  toward  the 
left  side  of  the  mother's  abdomen,  the  right  shoulder  to  her  right  side, 
the  left  to  her  left  side  (Fig.  99).  If  a  vaginal  examination  be  now 
made  (the  patient  lying  in  the  ordinary  obstetric  position),  and  the  os  be 
sufficiently  open,  the  finger  Mill  imj)inge  upon  the  ])rotuberanee  of  the 
right  parietal  bone,  M'hich  is  described  as  the  "presenting  part" — a  term 
which  has  received  various  definitions,  the  best  of  M'hich  is  probably  that 
adopied  by  Tyler  Smith — viz.  "that  portion  of  the  feetal  head  felt  most 
prominently  "within  the  circle  of  the  os  uteri,  the  vagina,  and  the  os 
tincre  in  the  successive  stages  of  labor."  If  the  tip  of  the  examin- 
ing finger  be  passed  slightly  upAvard,  it  M'ill  feel  the  sagittal  suture 
running  obli({uely  across  the  })elvis,  and  if  this  be  traced  dowmvard  and 
to  the  left  it  Mill  come  upon  the  triangular  posterior  fontanelle,  M'ith  the 
lambdoidal  sutures  diverging  from  it.  If  the  finger  could  be  passed 
sufficiently  high  in  the  o])])Osite  direction,  upward  and  to  the  right,  it 
Mould  come  upon  the  large  anterior  fontanelle;  but  at  this  time  that  is 
too  high  up  to  be  M'ithin  reach.     The  chin  is  slightly  flexed  upon  the 

'  Leisliuian's  System  of  Midv:ijery,  p.  341. 


MECHANISM  OF  DELIVERY  IN  HEAD  PRESENTATION.     27 rj 

sternum,  this  flexion,  as  we  shall  presently  see,  being  greatly  increased 
as  the  head  begins  to  descend. 

The  head  at  the  commencement  of  labor  generally  lies  within  the 

Fig.  99. 


Attitude  of  Child  in  First  Position  (o.l.a.).    (After  Hodge.) 

pelvic  brim,  especially  in  primiparse.      In  multiparas,  owing  to  the 
relaxation  of  the  abdominal  parietes,  the  uterus  is  apt  to  fall  some- 


FiG.  100. 


First  Position  (o.l.a.)  :  movement  of  flexion. 


what  forward,  and  the  head  consequently  is  more  entirely  above  the 
brim,  but  is  pushed  within  it  as  soon  as  labor  actually  commences. 


276  LABOR. 

Xaotxolo — and  his  doscriptioii  has  hccii  n(ln])ted  by  most  sul)So<juent 
writers — describes  the  head  at  this  period  as  lyiiiji;  ohrKjuely  in  relation 
to  the  brim,  the  right  parietal  bone,  on  whieh  the  examining  finger  im- 
pinges, being  snpposed  by  iiim  to  be  nuioh  lower  than  the  left.  The 
aceuraoy  of  this  view  has  of  late  years  been  contested,  and  it  is  now 
pretty  generally  a(bnitt('d  that  this  oblirjuity  does  n(»t  exist,  and  thatfthCi 
head  enters  the  brim  of  the  [)elvis  with  both  pai'ietal  bones  on  the  samel 
level,  and  with  its  biparietal  diameter  ])arallel  to  the  plane  of  the  inlefcl 
(Fig.  100).  Xaegcle's  view  was  adopted  partly  becanse  the  finger  always 
felt  the  right  parietal  protuberance  lowest,  and  partly  because  it  was  at 
that  point  that  the  caput  succe(hincuiu,  or  swelling  observed  on  the  head 
after  delivery,  was  always  formed.  Both  arguments  are,  however, 
fallacious;  forfthe  right  parietal  bone  is  the  })art  which  would  naturally 
be  felt  lowest,  on  account  of  the  oblique  position  of  the  pelvis  to  the 
trunk  ;hvhile  with  regard  to  the  caput  succedaneura  it  has  been  conclu- 
sively proved  by  Duncan  that  it  does  not  form  on  the  point  most 
exposed  to  pressure,  as  Naegele  assumed,  but  on"  the  part  of  the  head 
where  there  is  least  pressure;  that  is,  the  part  lying  over  the  axis  of  the 
vaginal  canal. 

Division  of  Mechanical  Movements  into  Stages. — In  tracing  the 
progress  of  the  head  from  the  position  just  described  obstetricians  have 
been  in  the  habit  of  dividing  the  movements  it  undergoes  into  various 
stages,  wkich  arc  convenient  for  the  purpose  of  facilitating  description. 
It  must  be  borne  in  mind  that  these  arc  not  evident  and  distinct  stages, 
which  can  always  be  made  out  in  practice,  but  that  they  run  insensibly 
into  one  another,  and  often  occur  simultaneously,  or  nearly  so,  in  rapid 
labor.  They  may  be  described  as — 1.  Flexion.  2.  First  movement  of 
descent.  3.  Levelling  or  afJjnsting  movement.  4.  Rotation.  5.  Second 
movement  of  descent  and  extension.     6.  External  rotation. 

1.  Flexion. — The  first  movement  of  the  head  consists  of  a  rotation  on 
its  biparietal  diameter,  by  which  the  chin  of  the  child  becomes  bent  on 
the  sternum  and  the  occiput  descends  lower  than  the  forakead.  Ev'tJi-is 
there  is  a  clear  gain  of  at  least  half  an  inch,  ibr  the  occipito-bregmatic 
diameter  (3J  inches)  becomes  substituted  for  the  occipito-frontal 
(4|  inches)  (Fig.  100). 

The  movement  is  most  marked  when  the  pelvis  is  narrow,  and  in 
some  cases  of  pelvic  deformity  it  takes  place  to  an  extreme  degree, 
while  in  unusually  large  and  roomy  pelves  it  occurs  to  a  very  slight 
extent  or  not  at  all.  QjThe  reason  of  this  flexion  is  twofold. (  Solayres  and 
the  majority  of  obstetricians  explain  it  by  saying  that  the  expulsive 
force  is  communicated  to  the  head  through  the  vertebral  column,  and, 
inasmuch  as  the  head  is  articulated  nnich  nearer  the  occijiut  than  the 
sinciput,  the  resistance  being  equal,  the  former  nuist  be  jnished  down. 
This  is  doubtless  the  correct  explanation  of  the  flexion  (fter  the  mem- 
branes are  rupturecV,  but  before  that  hapj^ens  the  ovum  is  practically  a 
bag  of  water,  which  is  equally  compressed  at  all  points  by  the  uterine 
contraction,  and  is  pushed  downward  through  the  os  en  ma.'isc,  the  expul- 
sive force  not  being  transmitted  through  the  vertebral  column  at  all. 
Under  such  circumstances  flexion  is  probably  effected  in  the  following 
way  :  the  head  being  articulated  nearer  the  occiput  than  the  forehead. 


MECHANISM  OF  DELIVERY  IN  HEAD  PRESENTATION.     277 

and  being  equally  pressed  iij)on  from  below  by  the  resisting  structures, 
the  pressure  is  more  effectual  on  the  forehead ;  consequently,  that  is 
forced  upward  and  the  occiput  descends.  This  explanation  would  also 
hold  good  after  the  rupture  of  the  membranes,  and  probably  Ijoth  causes 
assist  in  effecting  the  movement. 

2  and  3.  Descent  and  Levd/inf/  3Iovement. — The  movements  of  descent 
and  levelling  may  be  described  together.  As  soon  as  the  head  is  lib- 
erated from  the  os  uteri,  it  descends  pretty  rapidly  through  the  pelvis 
until  the  occiput  reaches  a  point  nearly  opposite  the  lower  part  of  the 
foramen  ovale  (Fig.  101)  and  the  sinciput  is  opposite  the  second  bone 

Fig.  101. 


First  Position  (o.l.a.)  :  Occiput  in  the  Cavity  of  the  Pelvis.    (After  Hodge.) 

of  the  sacrum.  A  levelling  movement  now  occurs  :  the  anterior  fonta- 
nelle  comes  to  be  more  easily  within  reach,  more  on  a  level  with  the  pos- 
terior, and  the  chin  is  no  longer  so  much  flexed  on  the  sternum.  (  This 
change  is  due  to  the  fact  that  the  antei'ior  end  of  the  ovoid  experiences 
greater  resistance  than  the  posterior,  and  as  soon  as  this  resistance  coun- 
terbalances and  exceeds  that  applied  to  the  latter  the  sinciput  must 
descend.")  The  right  side  of  the  head  also  descends  more  than  the  left 
from  a  similar  cause,  so  that  the  head  becomes,  as  it  were,  slightly 
flexed  on  the  right  shoulder.  This  obliquity  of  the  head  on  its  trans- 
verse diameter  in  the  lower  part  of  the  pelvis  has  been  denied  by 
Kiineke,^  who  maintains  that  the  head  passes  through  the  entire  pelvis 
in  the  same  position  as  it  enters  the  brim — that  is,  with  both  parietal 
bones  on  a  level — so  that  the  point  of  intersection  of  the  transverse  and 
antero-posterior  diameters  of  the  pelvis  would  correspond  with  the  sag- 
ittal suture.  There  is,  however,  good  reason  to  believe  that  in  the  lower 
half  of  the  pelvic  cavity  the  head  is  not  truly  synclitic,  as  Kiineke 
describes,  but  that  the  right  parietal  bone  is  on  a  somewhat  lower  level 
than  the  left. 

4.  Rotation. — The  movement  of  rotation  is  very  important.  By  it 
the  long  diameter  of  the  head  is  changed  from  the  oblique  diameter  of 
the  pelvic  cavity  to  the  antero-posterior  diameter  of  the  outlet  (Fig.  102), 
or  to  a  diameter  nearly  corresponding  to  it,  so  that  the  long  diameter  of 
the  head  is  brought  into  relation  with  the  longest  diameter  of  the  pelvic 
outlet.  This  alteration  almost  always  takes  place,  and  may  be  readily 
observed  by  the  accoucheur  who  carefully  watches  the  progress  of  labor. 
Various  explanations  have  been  given  of  its  causes.     The  one  most  gen- 

'  Die  tier  Factoren  der  Geburt,  Berlin,  1869. 


278  LABOR. 

orally  adopted  is  that  it  is  i\\\o  to  tlic  projcotion  inward  of  tlio  ischial 
spines,  \vhich  narrow  the  transverse  diameter  of  tiie  pelvic  outlet.  As 
tne~jtaius  force  the  occiput  downward  its  rotation  backward  is  proven tetl 
bv  the  projection  of  the  left  ischial  spine,  while  its  rotation  forward  is 
favored  by  the  smooth,  bevelled  surface  of  the  aseendin<r  ramus  of  tlie 


First  Position  (o.l.a.)  :  Occiput  at  Outlet  of  the  Pelvis.    (After  Hodge.) 

ischium.  Similarly,  the  ischial  spine  on  the  opposite  side  prevents  the 
rotation  forwai'd  of  the  forehead,  which  is  guided  backward  to  the 
cavity  of  the  sacrum  by  the  smooth  surface  of  the  sacro-ischiatic  liga- 
ments. These  arrangements,  therefore,  give  a  screw-like  form  to'the 
interior  of  the  pelvis ;  and  as  the  pains  force  the  head  downward,  they 
are  effectual  in  imparting  to  it  the  rotatory  movement  which  is  of  such 
importance  in  adajiting  it  to  tlie  longest  measurement  of  the  outlet. 

By  most  of  the  German  obstetricians  the  influence  of  the  ischial  spines 
and  of  the  smooth  })elvic  planes  in  producing  rotation  is  not  admitted. 
They  rather  refer  the  change  of  direction  to  the  increa.sed  resistance  the 
head  meets  from  the  posterior  wall  of  the  pelvis  and  from  the  perineal 
structures.  AVhichever  part  of  the  head  first  meets  this  resistance,  which 
is  much  greater  than  that  of  the  anterior  part  of  the  pelvis,  must  neces- 
sarily be  pressed  forward  ;  and  as,  in  the  large  majority  of  cases,  the  pos- 
terior fontanel le  descends  first,  it  is  thus  ])ressed  forward  until  rotation 
is  effected.  This  view  has  the  advantage  of  accounting  equally  well  for 
the  rotation  in  occipito-postcrior  as  in  occipito-anterior  positions,  the 
former  of  which,  on  the  more  ordinarily  received  theory,  are  not  quite 
sati.sfactorily  explicable.  It  does  not  follow  that  the  smooth  surfaces  of 
the  pelvic  planes  are  without  influence  in  favoring  the  rotation.  .  On 
the  contrary,  they  doubtless  greatly  facilitate  it ;  and  it  is  ]u*obable  that 
both  these  agencies  operate  in  producing  anterior  rotation  of  the  occiput. 

In  some  rare  cases  the  head  escapes  rotation  and  reaches  the  peri- 
neum still  lying  in  the  oblique  diameter.  Even  here,  however,  rotation 
is  generally  effected,  often  suddenly,just  as  the  head  is  about  to  pass  the 
vulva,  and  it  is  very  rarely  expelled  in  the  oblicjue  jiosition.  The 
movement  at  this  stage  may  be  explained  by  the  perineum,  which  is 
attached  at  its  sides  and  grooved  in  its  centre  :  to  the  hollow  so  formed 
the  long  diameter  of  the  head  accommodates  it.self,  and  is  thus  rotated 
into  the  antero-posterior  diameter  of  the  outlet. 

5.  Exten.sion. — By  the  jn-ocess  just  described  tiie  face  is  turned  back 
into  the  hollow  of  the  sacrum  ;  but  the  head  does  not  lie  absolutely  in 


MECHANISM  OF  DELIVERY  IN  HEAD  PRESENTATION.      279 

the  antero-posterior  diameter  of  the  i)elvic  outlet,  but  rather  in  one 
between  it  and  the  obli(jue.  Tlie  occiput  is  still  forced  down  Ijy  the 
pains,  and  in  consequence  of  its  altered  i^osition  is  enabled  to  pass 
between  the  rami  of  the  pubis,  and  advances  until  its  further  descent  is 
checked  by  the  nape  of  the  neck,  which  is  pressed  under  and  against  the 
arch  of  the  pubcs.  By  this  means  the  occiput  is  fixed,  and  tlic  pains 
continuing,  the  uterine  force  no  longer  acts  on  the  occiput,  but  on  the 
anterior  part  of  the  head,  which  is  now  pushed  down  and  separated  from 
the  sternum.  This  constitutes  extension.  As  the  head  descends  the  soft 
structures  of  the  perineum  are  stretched  and  the  coccyx  pushed  back  so 
as  to  enlarge  the  outlet.  The  pains  continue  to  distend  the  perineum 
more  and  more,  the  head  advancing  and  receding  with  each  pain.  As 
the  forehead  descends  the  suboccipito-bregmatic,  the  suboccipito-frontal, 
and  the  suboccipito-mental  diameters  successively  present ;  the  occiput 

Fig.  103. 


First  Position  (o.l.a.)  :  Head  Delivered.    (After  Hodge.) 

turns  more  and  more  upward  in  front  of  the  pubes  (Fig.  103),  and  at 
last  the  face  sweeps  over  the  perineum  and  is  born. 

The  mechanical  caiise  of  this  movement  may  be  readily  explained. 
As  soon  as  the  occiput  has  passed  under  the  arch  of  the  pubes,  and  is 
no  longer  resisted  by  the  anterior  pelvic  walls,  the  head  is  subjected  to 
the  action  of  two  forces — that  of  the  uterine  pressure,  acting  downward 
and  backward ;  and  that  of  the  resistance  of  the  posterior  walls  of  the 
pelvis  and  the  soft  parts,  acting  almost  directly  forward.  The  neces- 
sary result  is  that  the  head  is  pushed  in  a  direction  intermediate  between 
these  two  opposing  forces — that  is,  downward  and  forward  in  the  axis 
of  the  pelvic  outlet. 

In  addition  to  the  slight  obliquity  which  exists  as  regards  the  direct 
relation  of  the  long  diameter  of  the  head  to  the  antero-posterior  diam- 
eter of  the  outlet  at  the  moment  of  its  expulsion,  the  head  also  lies 
somewhat  obliquely  in  relation  to  its  own  transverse  diameter,  so  that 
in  the  majority  of  cases  the  right  parietal  bone  is  expelled  before  the 
left. 

6.  External  Rotation, — Shortly  after  the  head  is  expelled,  as  soon  as 
renewed  uterine  action  commences  it  may  be  observed  to  make  a  distinct, 
rotary  movement,  fthe  occiput  turning  to  the  left  thigh  of  the  mother  j 
and  the  face  turning  upward  to  the  right  thigh  (Fig.  104).     The  reason' 
of  this  is  evident.     When  the  head  descends  in  the  right  oblique  diam- 


280 


LABOR. 


oter  the  shoulders  lie  in  (lie  o])p()site  <»r  left  ohlicjiie  diameter,  and,  as 
the  head  rotates  into  the  antero-posterior  diameter,  they  are  neoessirilv 
})laced  more  nearly  in  the  transverse.  As  soon  as  the  head  is  expelled 
the  shoulders  are  subjeeled  to  the  same  uterine  loree  and  j)elvie  resisl- 


FiG.  104. 


External  Rotation  of  Head  in  First  Position  (o.l.a.).    (After  Hodge.) 

ance  as  the  liead  has  just  been,  and  they  are  acted  on  in  jn'eciscly  the 
same  way.  Consequently  they  too  rotate,  but  in  the  opposite  direction, 
into  the  antero-posterior  diameter  of  the  outlet,  or  nearly  so,  just  as  the 
head  did,  and  as  they  do  so  they  necessarily  carry  the  head  -with  them 
and  cause  its  external  rotation. 

The  two  shoulders  are  soon  expelled,  the  left  shoulder  generally  the 
firstj  sweeping  over  the  perineum  in  the  same  manner  as  the  face.  This 
is,  however,  not  always  the  ease,  and  they  are  often  expelled  simidta- 
iieously,  or  the  right  shoulder  may  come  first.  The  body  soon  follows, 
and  the  second   stage  of  labor  is  completed. 

Second  Position. — In  the  second  position  (o.d.a.)  the  long  diameter 
of  the  head  lies  in  the  left  oblique  diameter  of  the  pelvis.  On  making 
a  vaginal  examination  in  the  ordinary  obstetric  position,  the  finger, 
passing  upward  and  to  the  right,  feels  the  small  posterior  foutanelle ; 
downward  and  to  the  left,  it  feels  the  anterior.  The  sagittal  suture  lies 
ol)liquely  across  the  pelvis  in  the  left  oblique  diameter.  The  description 
of  the  mechanism  of  delivery  is  j)recisely  the  same  as  in  the  first  ]M>si- 
tion  (o.l.a.),  substituting  the  Avord  "  left  "  for  "  right."  Thus  the  finger 
im})inges  on  the  left  parietal  bone  ;  the  occiput  turns  from  right  to  left 
during  rotation.  After  the  birth  of  the  head  the  occiput  turns  to  the 
right  thigh  of  the  mother,  the  face  to  the  left  thigh. 

Third,  or  Right  Occipito-sacro-iliac  Position. — In  the  third  j)osi- 
tion  (o.D.P.)  the  head  enters  the  pelvic  brim  with  the  <>ci'i))ut  direete(l 
backward  to  the  rigiit  sacro-iliac  synchondrosis,  and  the  sinciput  ibr- 
ward  to  the  left  foramen  ovale  (Fig.  105).  The  posterior  fontanelle  is 
directed  backward,  the  anterior  fontanelle  forward,  while  the  examining 
finger  impinges  on  the  left  parietal  bone.  The  mechanism  of  delivery 
in  these  cases  is  of  much  interest.     In  the  large  majority  of  cases  dur- 


MECHANISM  OF  DELIVERY  IN  HEAD  PRESENTATION.      281 

iiig  the  jirogress  of  delivery  the  occiput  rotates  forwaixl  along  the  right 
side  of  the  pelvis,  until  it  comes  to  lie  almost  in  the  antero-posterior 
diameter  of  the  outlet  and  passes  under  the  pubic  arch,  the  forehead 
passing  over  the  perineum.  It  will  be  seen  that  during  part  of  this 
extensive  rotation  the  head  must  lie  in  the  second  position  (o.d.a.),  and 


Third  Position  (o.d.p.)  of  Occiput,  at  Brim  of  Pelvis. 

the  case  terminates  just  as  if  it  had  been  in  the  second  position  (o.d.a.) 
from  the  commencement  of  labor. 

Manner  in  ■which  the  Occiput  is  Rotated  For"ward. — How  is  it 
that  this  rotation  is  eifected,  and  that  the  sinciput,  occupying  the  position 
of  the  occiput  in  the  first  position  (o.l.a.),  should  not  be  rotated  for- 
ward to  the  pubes,  as  that  is?  This,  no  doubt,  may  be  explained  by  the 
fact  that  the  uterine  force  transmitted  through  the  vertebral  column 
causes  the  occiput  to  descend  lower  than  the  sinciput,  so  that  in  most 
cases  in  making  a  vaginal  examination  the  posterior  fontanelle  can  be 
readily  felt,  while  the  anterior  is  high  up  and  out  of  reach.  The  head 
is  therefore  extremely  flexed,  and  so  descends  into  the  pelvic  cavity, 
until  the  occipui,  being  how  below  the  right  ischial  spine,  experiences 
the  resistance  of  the  pelvic  floor  opposite  the  right  sacro-ischiatic  liga- 
ment, by  which  it  is  directed  forward.  The  forehead  is,  at  this  time, 
supposing  flexion  to  be  marked,  too  high  to  be  influenced  by  the  ante- 
rior pelvic  plane.  Pressure  continuing,  the  occiput  rotates  forward,  the 
forehead  passes  round  the  left  side  of  the  pelvis,  and  labor  is  terminated 
as  in  the  second  position  (o.d.a). 

The  period  of  labor  at  which  rotation  takes  place  varies.  In  the 
majority  of  cases  it  does  not  occur  until  the  head  is  on  the  floor  of  the 
pelvis,  for  it  is  then  that  resistance  is  most  felt ;  but  the  greater  the 
resistance  the  sooner  will  rotation  be  produced.  Hence  it  is  more  likely 
to  occur  early  when  the  head  is  large  and  the  pelvis  comparatively 
small. 

The  facility  with  which  this  movement  is  effected  obviously  depends 


282  LABOR. 

u[»un  tlu'  coinplett'  flexion  of  the  chin  on  the  sternum,  hy  which  the 
anterior  fontanelle  is  so  elevated  that  its  rotation  backward  is  not  resLsted 
l)v  the  inward  jjrojcction  of  tlic  left  ischial  spine,  and  theoc-cipnt  is  cor- 
respondingly depressed.  If,  |m»ovpr^  fl.;<  ^\^.^^\au  is  pot  complete,  rnid 
the  anterior  fnntanelle  is  so  low  as  to  be  readily  within  reach  of  the 
finger,  considerable  difficulty  is  likely  to  be  experienced.  In  many  such 
cases  rotation  is  still  eventually  effected,  but  in  others  it  is  not ;  and  tiie 
labor  is  then  terminated  Avith  the  face  to  the  pubes,  but  at  the  expense 
of  considerable  delay  and  ditliculty.  According-  to  Dr.  Uvedale  West 
of  Alford,  who  devoted  much  careful  study  to  the  subject,  this  termi- 
nation occurs  in  about  4  per  cent,  of  occipito-posterior  positions.  When 
it  is  about  to  happen  the  anterior  fontanelle  may  be  felt  very  low  down, 
and  soiuetimes  even  the  forehead  and  superciliary  ridges.  The  utei'ine 
force  pushes  down  the  occiput,  the  sinciput  l)eing  fixed  behind  the 
pubes,  which  it  obviously  cannot  pass  under,  as  does  the  occiput  in  the 
fii'st  position.  The  sinciput,  therefore,  becomes  more  flexed  and  pushed 
upward,  while  the  resistance  of  the  pelvic  floor  directs  the  occii)ut  for- 
ward. The  perineum  now  becomes  enormously  distended  by  the  back 
part  of  the  head,  and  is  in  great  danger  of  laceration.  The  occiput  is 
eventually,  but  not  without  much  difficulty,  expelled.  A  process  of 
extension  now  occurs,  the  nape  of  the  neck  being  fixed,  as  it  were, 
against  the  centre  of  the  perineum,  the  expelling  force  now  acting  on 
the  forehead,  and  producing  rotation  of  the  head  on  its  transverse  axis. 
The  forehead  and  face  are  thus  protruded,  and  the  body  follows  without 
difficulty. 

It  is  said  that  in  a  few  exceptional  cases,  where  the  anterior  fonta- 
nelle is  much  depressed,  the  labor  may  terminate  l)v  the  conversion  of 
the  presentation  into  one  of  the  face,  the  head  rotating  on  its  transverse 
axis,  the  forehead  passing  to  the  posterior  part  of  the  pelvis,  and  the 
chin  emerging  under  the  perineum.  It  is  obvious,  however,  that  this 
change  can  only  occur  when  the  head  is  unusually  small,  and  it  must 
of  necessity  be  extremely  rare. 

Reference  has  already  been  made  to  Xaegele's  views  as  to  the  rarity 
of  the  second  position  (o.d.a.),  and  to  his  o])inion  that  cases  in  which 
the  occiput  was  found  to  point  to  the  right  foramen  ovale  were  only 
transitional  stages  in  the  rotation  of  occipito-posterior  positions.  Sucli 
an  assumjition,  however,  is  unwarrantable,  unless  the  case  has  been 
watched  from  the  very  commencement  of  labor.  Many  perfectly  qual- 
ified observers  have  arrived  at  the  conclusion  that  second  ])ositions 
(o.d.a.)  are  far  more  common  than  Xaegele  sujiposed  ;  and  in  the  table 
already  quoted  it  will  be  seen  that  while  ]\fur])liy  estimates  the  second 
(o.d.a.)  and  third  (o.D.P.)  as  being  equally  I'requent,  Swayne  believes 
the  second  (o.d.a.)  to  be  much  more  common  than  the  third  (o.D.P.). 
It  is  probable  that  the  weight  of  Naegele's  authority  has  induced  many 
observers  to  classifv  second  (o.d.a.)  jiositions  as  third  (o.D.P.)  jiositions 
in  which  partial  rotation  has  already  been  acconn)lished.  ^ly  own 
experience  would  certainly  lead  me  to  think  that  second  (o.d.a.)  posi- 
tions are  very  far  from  uncommon.  The  question,  however,  must  be 
considered  to  be  in  abeyance-until  t'urther  observations  by  competent 
authorities  enable  us  to  decide  it  conclusively. 


I 


MECHANISM  OF  DFJJVERY  IN  HEAD  PRESENTATION.      283 


Fourth  or  Left  Occipito-sacro-iliac  Position. — Tho  fourth  position 
(o.T..i>.)  is  just  as  luucli  (he  ivverse  of  the  sec-ond  as  the  third  is  of  the 
first.    The' occiput  points  to  the  left  (Fig.  106)  sacro-iliac  synchondrosis, 


Fig.  106. 


Fourth  Position  (o.l.p.)  of  Occiput  at  Pelvic  Brim. 

and  the  finger  impinges  on  the  right  parietal  bone.  The  mechanism  is 
precisely  the  same  as  in  the  third  position  (o.d.p.),  the  rotation  taking 
place  from  left  to  right. 

Formation  of  the  Caput  Succedaneum. — The  formation  of  the 
caput  succedaneum  has  been  already  alluded  to.  /This  term  is  applied 
to  the  oedematous  swelling  which  forms  on  the  head,  and  is  produced 
by  effusion  from  the  obstruction  of  the  venous  circulation  caused  by  the 
pressure  to  which  the  head  is  subjectedA  It  follows  that  the  size  of  the 
swelling  is  in  direct  proportion  to  the  length  of  the  laborj  In  rapid 
deliveries,  in  ^vhich  the  head  is  forced  through  the  pelvis  quickly,  it  is 
scarcely,  if  at  all,  developed  ;  while  after  protracted  labor  it  is  large  and 
distinct,  and  may  obscure  the  diagnosis  of  the  position  by  preventing 
the  sutures  and  fontanelles  being  felt.  Its  situation  varies  according  to 
the  position  of  the  head;  thus,  in  the  first  (o.l.a.)  and  fourth  (o.l.p.) 
positions  it  forms  on  the  right  parietal  bone,  in  the  second  (o.d.a.)  and 
third  (o.D.P.)  on  the  left ;  and  we  may  therefore  verify  by  inspection 
of  its  site  the  accuracy  of  our  diagnosis. 

An  ordinary  mistake  which  has  been  made  by  obstetricians  is  to 
regard  the  caput  succedaneum  as  formed  at  the  point  where  the  head 
has  been  most  subjected  to  pressure,  while  in  fact  it  forms  on  that  part 
Avhich  is  most  unsupported  by  the  maternal  structures,  and  where  the 
swelling  may  consequently  most  readily  occur.  Therefore,  in  the  early 
stages  of  the  labor  it  always  forms  on  the  part  of  the  head  which  lies 
in  the  circle  of  the  os  uteri^  while  in  subsequent  stages  it  forms  on  that 
which  lies  in  the  axis  of  the  vaginal  canal,  and  eventually  is  most 
prominent  on  the  part  that  is  first  expelled  from  the  vulva. 

Alteration  in  the  Shape  of  the  Head  from  Moulding-. — A  few 
words  may  be  said  as  to  the  alteration  in  the  form  of  the  fetal  head 
which  occurs  in  tedious  labors,  and  results  from  the  moulding  which  it 
has  undergone  in  its  passage  through  the  pelvis.  The  smaller  the  pelvis 
and  the  greater  the  pressure  applied  to  the  head  during  the  delivery, 


284  LABOR. 

the  more  nmrkcd  is  tliis.  Tho  result  is  that  in  vortex  presentations  the 
ot'eii)ito-niental  anil  occipito-f'rontal  (iianictoi-s  arc  elongated  to  the 
extent  of  an  inch  or  even  more,  ■\vliilc  the  transverse  diamcteis  are 
lessened  from  compression  of  the  parietal  bones.  This  moulding  is 
of  iniqucstionable  value  in  facilitating  the  birth  of  the  child.  The 
amount  of  apparent  deformity  is  very  considerable,  and  may  even  give 
rise  to  some  anxiety.  It  is  ■well  to  remendjcr,  tiierclbre,  that  it  is 
always  transient,  and  that  in  a  few  hours,  or  days  at  most,  the  elasticity 
of  the  soft  cranial  bones  causes  them  to  resume  their  natural  form. 
The  caput  succedanenm  also  disappears  rapidly;  therefore  no  amount 
of  deformity  from  either  of  these  causes  need  give  rise  to  anxiety  or 
call  for  any  treatment. 

CHAPTER  HI. 

MANAGEMENT  OF  NATURAL  LABOR. 

Although  labor  is  a  strictly  physiological  function,  and  in  a  large 
majority  of  cases  might,  no  doubt,  be  safely  accom})lislied  without  assist- 
ance from  the  accoucheur,  still,  medical  aid,  properly  given,  is  always 
of  value  in  facilitating  the  process,  and  is  often  absolutely  essential  for 
the  safety  of  the  mother  and  child. 

Preparatory  Treatment. — The  management  of  the  pregnant  woman 
before  delivery  is  a  point  which  should  always  receive  the  attention  of 
the  medical  attendant,  since  it  is  of  consequence  that  the  labor  should 
come  on  when  she  is  in  as  good  a  state  of  health  as  ])Ossible.  For  this 
purpose  ordinary  hygienic  ])recautions  should  never  be  neglected  in  the 
latter  months  of  gestation.  The  jiatient  should  take  regular  and  gentle 
exorcise  short  of  fatigue,  and,  if  the  weather  permit,  should  spend  as 
nuieh  of  her  time  as  possible  in  the  open  air.  Hot  I'ooms,  late  hours, 
and  oxeitoniont  of  all  kinds  should  be  strictly  avoided:  The  diet 
should  be  simple,  nutritious,  and  unstimulating.  The  state  of  the 
bowels  should  be  strictly  attended  to.  During  the  few  days  preceding 
labor  the  descent  of  the  uterus  often  causes  ])rcssurc  on  the  rectum  and 
prevents  its  evacuation.  Hence  it  is  customary  to  prescribe  occasional 
gentle  a_perieuts,  such  as  small  doses  of  castoi*  oil,  for  a  few  days  before 
the  expeetecTperiod  of  delivery.  Some  caution,  however,  is  necessary, 
as  it  is  certainly  not  very  uncommon  for  labor  to  be  determined  rather 
sooner  than  was  anticipated,  in  conse(|uence  of  the  irritation  of  too 
large  a  purgative  dose.  The  state  of  the  bowels  should  always  be 
inquired  into  at  the  commencement  of  labor,  and,  if  there  be  any 
reason  to  susjiect  that  they  are  loaded,  a  co])ious  enema  should  be 
administered.^  This  is  always  a  proper  ])recaution  to  take,  for  a  loaded 
rectum  is  a  common  cause  of  irregular  and  ineffective  uterine  action  ; 


MANAGEMENT  OF  NATURAL  LA  BOB.  285 

and  even  when  it  does  not  produce  this  result,  the  escape  of  the  feces 
in  consequence  of  pressure  on  the  bowel  during  the  propulsive  stage  is 
always  disao-rccahlo  both  to  tlie  patient  and  practitioner. 

The  dress  of  the  patient  during  pregnancy  may  be  here  adverted 
to,  for  much  discomfort  may  arise  and  tiie  satisfactory  progress  of  labor 
may  even  be  interfered  with  from  errors  in  this  respect. 

After  the  uterus  has  risen  out  of  the  pelvis  the  ordinary  corset  which 
most  women  wear  is  apt  to  produce  very  injurious  pressure ;  still  more 
so  when  attempts  are  made  to  conceal  the  increased  size  by  tight  lacing. 
After  the  fourth  or  fifth  month,  therefore,  the  comfort  of  the  patient  is 
much  increased  by  wearing  a  specially-constructed  pair  of  stays  with 
elastic  let  into  the  sides  and  front,  so  that  they  accommodate  them- 
selves to  the  gradual  increase  of  the  figure.  Such  are  made  by  all  stay- 
makers,  and  should  be  worn  whenever  the  circumstances  of  the  patient 
.permit.  Failing  this,  it  is  better  to  avoid  the  use  of  the  corset 
altogether,  and  to  have  as  little  pressure  on  the  uterus  as  possible, 
although  many  women  cannot  do  without  the  support  to  which  they 
are  accustomed.  To  multiparse,  especially  if  there  be  much  laxity  of 
the  abdominal  parietes,  a  well-fitting  elastic  abdominal  belt  is  often  a 
great  comfort.  This  is  constructed  so  that  it  can  be  tightened  when  the 
patient  is  walking  and  in  the  erect  position,  w^hen  such  support  is  most 
required,  and  readily  loosened  when  desired. 

Necessity  of  Attending  to  the  First  Summons. — It  is  hardly// 
necessary  to  insist  on  the  necessity  of  the  practitioner  attending  irame-l/ 
diately  to  the  first  summons  to  the  patient.  It  is  true  that  he  may  very' 
often  be  sent  for  long  before  he  is  actually  required.  But,  on  the  other 
hand,  it  is  quite  impossible  to  foresee  what  may  be  the  state  of  any  in- 
dividual case.  By  prompt  attention  he  may  be  able  to  rectify  a  mal- 
position or  prevent  some  impending  catastrophe,  and  thus  save  his 
patient  from  consequences  of  the  utmost  gravity. 

The  practitioner  should  always  be  provided  with  the  articles  which 
he  may  require.  The  ordinary  obstetric  cases,  containing  one  or  two 
bottles  and  a  catheter,  such  as  are  sold  by  most  instrument-makers,  are 
cumbrous  and  useless,  while  "obstetric  bags"  are  expensive  luxuries 
not  within  the  reach  of  all.  Every  one  can  manufacture  an  excellent 
obstetric  bag  for  himself  at  a  small  expense  by  having  compartments 
for  holding  bottles  stitched  on  to  the  sides  of  an  ordinary  leather  bag,  j^^  ^^ 
such  as  is  sold  for  a  few  shillings  at  any  portmanteau-maker's.  It  is  a  VT  ^  o 
great  comfort  to  have  at  hand  all  that  may  be  required,  and  the  bag  y* 

should  contain  chloroform  or  other  anaesthetic,  antiseptics  in  a  concen-       (V/* 
trated  form,  chloral,  laudanum,  the  liquor  ferri  perchloridi  of  the  Phar-  ^kJ 
macopoeia,  the  liquid  extract  of  ergot,  and  a 'liypoclermic  S3''ringe,  with  V 
bottles  containing  caibolized  oil,  ether,  and  a  solution  of  ergotiue  for 
subcutaneous  injection.     If  it  also  contain  a  Higginson's  ^^[uge,  a 
small  elastic  catheter,  a  good  pair  of  forceps,  and  one  or  two  suture- 
needles,  with  some  silver  wire  or  carbolized  catgut,  the  practitioner  is 
provided  against  any  ordinary  contingency.     Other  articles  that  may  be 
required,  such  as  thread,  scissors,  and  the  like,  are  generally  provided 
by  the  nurse  or  patient. 

Duties  on  First  Visiting  the  Patient. — On  arriving  at  the  house 


286  LABOR. 

the  ]>i-a('titioiior  slioiild  liavc  liis  visit  annoiinced  to  tlic  paticDt,  and  lie 
will  very  oltcn  liiid  that  the  lirst  eilect  of  his  jiresenee  is  to  arrest  the 
pains  that  have  been  hitherto  i)roj;res.sin^  rai)idly,  thereby  allbrdinj;  a 
very  conclusive  jn-oof  of"  the  influence  of  mental  inij)ressions  on  the 
progress  of  labor.  If  the  ])ains  be  not  already  ])ropulsive,  it  is  ^vell 
that  lie  should  occujiy  himself  at  first  in  general  in<|uiri('s  from  the 
attendants  as  to  the  progress  of  the  labor,  and  in  seeing  that  all  the 
necessary  arrangements  are  satisfactorily  carried  out,  so  as  to  allow  the 
patient  time  to  get  accustomed  to  his  presence.  If  he  have  any  choice 
in  the  matter,  lie  should  endeavor  to  secure  a  large,  airy,  and  well- 
ventilated  apartment  for  the  lying-in  room,  as  far  removed  as  possible 
from  Mithout.  He  may  also  see  to  the  bed,  Mliich  should  be  without 
curtains  and  jn-epared  for  the  labor  by  having  a  waterproof  sheeting 
laid  under  a  folded  blanket  or  sheet,  ou  Avhich  the  })atient  lies.  These 
receive  the  discharges  during  labor,  and  can  be  pulled  from  under  the 
patient  after  delivery,  so  as  to  leave  the  diy  clothes  beneath.  ["We 
would,  in  this  connection,  particularly  recommend  to  accoucheurs  the 
caoutchouc  dam  and  a])ron  devised  as  a  protector  and  conduit  by  Prof. 
Howard  A.  Kelly  of  Philadelphia,  as  it  not  only  prevents  the  soiling 
of  the  bed  and  the  undergarments  of  the  patient,  but  will  admit  of  a 
reliable  measurement  of  the  amniotic  fluid  when  in  excess,  and  of  that 
removed  from  the  head  by  tapping  in  hydrocephalus.  It  has  been 
found  specially  useful  in  cases  of  emergency  and  in  practice  among  the 
poor  and  unprepared. — Ed.]  Among  the  lower  classes  the  lying-in 
chamber  is  considered  a  legitimate  meeting-place  for  numerous  female 
friends  to  gossip,  whose  conversation  is  often  distressing,  and  is  certainly 
injurious,  to  a  woman  in  the  excitable  condition  associated  with  labor. 
The  medical  attendant  should  therefore  insist  on  as  much  quiet  as  pos- 
sible, and  should  allow  no  one  in  the  room  except  the  nuree  and  some 
one  friend  whose  presence  the  jiatient  may  desire.  The  husband's 
presence  must  be  left  to  the  wishes  of  the  patient.  Some  women 
like  their  husbands  to  be  with  tliem,  while  others  prefer  to  be  without 
them ;  and  the  medical  attendant  is  bound  to  act  in  accordance  with  the 
patient's  desire. 

If  pains  be  actually  present  a  vaginal  examination  is  essential,  and 
should  not  be  delayed.  It  enables  us  to  ascertain  whether  the  labor  has 
commenced  or  not,  and  whether  the  presentation  is  natural  or  otherwise. 
The  pains,  although  apparently  severe,  may  be  altogether  spurious,  and 
labor  may  not  have  actually  commenced.  It  is  of  much  imjK)rtance, 
both  for  our  own  credit  and  comfort,  that  we  should' be  able  to  diagnose 
the  true  character  of  the  ])ains;  for  if  they  be  so-called  "false"  jiains, 
we  might  wait  hours  in  fruitless  expectation  of  ]>rogress,  while  delivery 
is  still  far  off.  The  necessity  of  ascertaining,  therefore,  the  actual  state 
of  affairs  need  not  further  be  insisted  on.  [In  this  connection  we 
desire  to  remind  the  obstetrician  that  the  vagina  of  the  ])atient  and  his 
own  hands  should  be  rendered  aseptic  before  he  employs  his  index  linger 
in  making  "the  touch."  A  ]>hysician  with  ozaena  should  never  practise 
obstetrics,  for  fear  of  poisoning  his  ]>atient  by  the  touch  after  using  his 
handkerchief.     Many  deaths  have  been  in  this  way  produced. — Ed.] 

False  pains  are  chiefly  characterized  by  their  irregularity,  sometimes 


MANAGEMENT  OF  NATURAL  LABOR.  287 

coming  on  at  short  intci'vals,  sometimes  Avith  many  liours  between 
them:  they  also  vary  much  in  intensity,  some  being  very  sharp  and 
])ainfnl,  while  others  ai"e  slight  and  transient.  In  these  respects  they 
diHer  from  the  true  pains  of"  the  first  stage,  which  are  at  first  slight  and 
short,  and  gradually  recur  with  increased  force  and  regularity.  /The 
situation  of  the  two  kinds  of  ])ains  also  varies,  the  false  pains  being 
chiefly  situated  in  front,  while  the  true  pains  are  felt  most  in  the  back 
and  gradually  shoot  round  toward  the  abdomen.)  Nothing  short  of  a 
vaginal  examination  will  enable  us  to  clear  up  the  diagnosis  satisfac- 
torily, [i  If  the  labor  have  actually  commenced,  the  os  will  be  more  or( 
less  dilated  and  its  edges  thinned,  while  with  each  jmin  the  cervix  will  J 
become  rigid  and  the  membranes  tense  and  prominent.)  The  false  | 
pains,  on  the  contrary,  have  no  effect  on  the  cervix,  which  remains 
flaccid  and  undilated,  or,  if  the  os  be  sufficiently  open  to  admit  the  tip 
of  the  finger,  the  membranes  will  not  become  prominent  during  the 
contraction.  Under  such  circumstances  we  may  confidently  assure  the 
patient  that  the  pains  are  false,  and  measures  should  be  taken  to  remove 
the  irritation  which  produces  them.  '  In  the  large  majority  of  cases  the 
cause  of  the  spurious  pains  will  be  found  to  be  some  disordered  state  of 
the  intestinal  tract;)  and  they  will  be  best  remedied  by  a  gentle  aperient, 
such  as  castor  oil  or  the  compound  colocynth  pill  with  hyoscyamus,  fol- 
lowed by  or  combined  with  a  sedative,  such  as  twenty  minims  of  lauda- 
num or  chlorodyne.  Shortly  after  this  has  been  administered  the  false 
pains  will  die  away,  and  not  recur  until  true  labor  commences. 

Mode  of  Conducting  a  Vaginal  Examination. — For  a  vaginal 
examination  the  patient  is  placed  by  the  nurse  on  her  left  side,  close  to 
the  edge  of  the  bed,  with  the  legs  flexed  on  the  abdomen.  The  practi- 
tioner, being  seated  by  the  edge  of  the  bed,  passes  the  index  finger  of 
the  right  hand,  the  proper  antiseiDtic  precautions  having  previously  been 
taken,  up  to  the  vulva,  and  gently  insinuates  it  into  the  orifice  of  the 
vagina,  then  pushes  it  backward  in  the  axis  of  the  vaginal  outlet,  and 
finally  turns  it  upward  and  forward,  so  as  to  more  readily  reach  the  cer- 
vix (Fig.  107).  This  it  may  not  always  be  easy  to  do,  for  at  the  com- 
mencement of  labor  the  cervix  may  be  so  high  as  to  be  reached  with 
difficulty,  or  it  may  be  directed  backward  so  as  to  point  toward  the 
cavity  of  the  sacrum.  vThe  exploration  is  often  much  facilitated  by 
depressing  the  uterus  from  Avithout  by  the  left  hand  placed  on  the  abdo- 
men. Our  object  is  not  only  to  ascertain  the  state  of  the  cervix  as  to 
softness  and  dilatation,  but  also  the  presentation,  the  condition  of  the 
vagina,  and  the  capacity  of  the  pelvis.  /The  examination  is  generally 
commenced  during  a  j^ain,  at  which  time  it  is  less  depressing  to  the 
patients  but  in  order  to  be  satisfactory  the  finger  must  remain  in  the 
vagina  until  the  pain  is  over,  the  examination  being  concluded  in  the 
interval  between  this  pain  and  the  next. 

In  head  presentation  the  round  mass  of  the  cranium  is  generally  at 
once  felt  through  the  lower  part  of  the  uterus,  and  then  Ave  have  the 
satisfaction  of  being  able  to  assure  the  patient  that  all  is  right.  If  the 
OS  be  sufficiently  dilated,  we  can  also  feel  through  it  the  occiput  covered 
by  the  membranes.  ( It  is  im]2pssible  at  this  time  to  make  out  the  exact 
position  of  the  head  by  means  of  the  sutures  and  fontauelles,  which 


288 


LABOR. 


are  too  liigli  up  to  bo  Avitliin  reach. )  Nor  should  any  attempt  l)e  made 
to  do  so,  for  fear  of  prematurely  rupturing  the  membranes.  The  fact 
that  the  head  is  presenting  is  all  that  we  require  to  know  at  this  stage 
of  the  labor. 

The  condition   of   the  os   itself  as   to   rigidity  and   dilatation  -M-ill 
materially  assist  us  in  ibrming  an  opinion  as  to  the  progress  and  proba- 

FiG.  107. 


Examination  during  the  First  Stage. 


ble  duration  of  the  labor;  but,  although  the  friends  will  certainly  press 
for  an  opinion  on  this  point,  the  cautious  practitioner  will  be  careful 
not  to  commit  himself  to  a  positive  statement  which  may  so  easily  be 
falsified.  It  will  suffice  to  assure  the  friends  that  everything  is  satis- 
factory, but  that  it  is  impossible  to  say  with  any  certainty  how  rajiidly 
or  the  reverse  the  case  may  progress. 

If  the  pains  be  not  very  frequent  or  strong,  and  the  os  not  dilated  to 
more  than  the  size  of  a  shilling,  a  considerable  delay  may  be  anticipated 
and  the  presence  of  the  medical  attendant  is  useless.  He  may  therefore 
safely  leave  the  patient  for  an  hour  or  more,  provided  he  be  within 
easy  reach.  It  is  needless  to  say  that  this  should  never  be  done  unless 
the  exact  presentation  be  made  out.  If  some  part  other  than  the  head 
be  presenting,  it  M'ill  probably  be  impossible  to  make  it  out  until  dilata- 
tion has  progressed  further ;  and  the  practitioner  must  be  incessantly  on 
the  watch  until  the  nature  of  the  case  be  made  out,  so  as  to  be  able  to 
seize  the  most  favorable  moment  for  interference,  should  that  be  necessary. 

Position  of  Patient  during-  First  Stage. — The  position  of  the 
patient  is  a  matter  of  some  moment  in  the  first  stage.  It  is  a  decided 
advantage  that  she  should  not  be  then  in  a  recumbent  position  on  her 
side,  as  is  usual  in  the  second  stagey,  for  it  is  o?  importance  that  the 


MANAGEMENT  OF  NATURAL  LABOR.  289 

expulsive  force  should  act  iu  siieli  a  M^ay  as  to  favor  the  descent  of  the 
head  into  the  pelvis — /.  c.  perpendicularly  to  the  plane  of  its  brim — and 
also  that  the  weight  of  the  child  should  operate  in  the  same  way. 
([riierefore,  the  ordinary  custom  of  allowing  the  patient  to  walk  about  I 
or  to  recline  in  a  chair  is  decidedly  advantageous^  and  it  will  often  be' 
observed  that  the  ])ains  are  more  lingering  and  ineftective  if  she  lie  in 
bed.  (  If  the  patient  be  a  multipara  or  if  the  abdomen  be  somewhat 
])endulous,  an  abdominal  bandage,  by  supporting  the  uterus,  will  greatly 
favor  the  progress  of  this  stage.  )  Keeping  the  patient  out  of  bed  has 
the  further  advantage  of  preventing  her  being  unduly  anxious  for  the 
termination  of  the  labor,  and  a  little  cheerful  conversation  will  keep 
up  her  spirits  and  obviate  the  mental  depression  which  is  so  common. 
Good  beef-tea  may  be  freely  administered,  with  a  little  brandy  and 
water  occasionally  if  the  patient  be  weak,  and  will  be  useful  in  sup- 
porting  her  strength.   ^' 

Over-frequent  vaginal  examinations  at  this  period  should  be  avoided, 
for  they  serve  no  useful  purpose  and  are  apt  to  irritate  the  cervix.  It 
will  be  necessary,  however,  to  ascertain  the  progress  of  the  dilatation 
at  intervals. 

When  once  the  os  is  fully  dilated  the  membranes  may  be  artificially 
ruptured  if  they  have  not  broken  spontaneously,  for  they  no  longer 
sei-ve^any  useful  purpose  and  only  retard  the  advent  of  the  propulsive 
stage.  \  This  can  be  easily  done  by  pressing  on  them,  when  they  are 
rendered  tense  during  a  pain,  by  some  pointed  instrument,  such  as  the 
end  of  a  hairpin,  which  is  always  at  hand.  In  some  cases,  indeed,  it  is 
even  expedient  to  rupture  the  membranes  before  the  os  is  fully  dilated. 
Thus  it  not  unfrequently  happens,  when  the  amount  of  liquor  amnii  is 
at  all  excessive,  that  the  os  dilates  to  the  size  of  a  silver  dollar  or 
more  ;  but,  although  it  is  perfectly  soft  and  flaccid,  it  opens  up  no 
farther  until  the  liquor  amnii  is  evacuated,  when  the  propulsive  pains 
rapidly  complete  its  dilatation.  Some  experience  and  judgment  are 
required  in  the  detection  of  such  cases,  for  if  we  evacuate  the  liquor 
amnii  prematurely  the  pressure  of  the  head  on  the  cervix  might  pro- 
duce irritation  and  seriously  prolong  the  labor.  This  manoeuvre  is 
most  likely  to  be  useful  when  the  pains  are  strong  and  the  os  perfectly 
flaccid,  but  when  the  membranes  do  not  protrude  through  the  os  so  as 
to  effect  further  dilatation. 

It  is  sometimes  not  easy  to  ascertain  whether  the  membranes  are  rup- 
tured or  not.  This  is  most  likely  to  be  the  case  when  the  head  is  low 
down  and  the  amount  of  liquor  amnii  is  so  small  that  the  pouch  does 
not  become  prominent  during  the  pains.  A  little  care,  however,  Mill 
enable  us,  if  the  membranes  are  ruptured,  to  feel  the  rugosities  of  the 
scalp  covered  witli  hair,  and  to  distinguish  it  from  the  smooth  polished 
surface  of  the  membranes. 

After  the  evacuation  of  the  liquor  amnii  there  is  generally  a  lull  in 
the  progress  of  the  labor,  the  pains,  however,  soon  recurring  with  in- 
creased force  and  frequency,  and  propelling  the  head  through  the  pelvic 
cavity.  The  change  iu  the  character  of  the  pains  is  soon  appreciated 
by  the  bearing-down  efforts  by  which  they  are  accompanied,  as  well  as 
by  their  increased  length  and  intensity. 


2i)()  LAJiOR. 

Position  of  the  Patient  during  the  Second  Stage. — It  is  now 
ndvi.siMc-  that  tlu'  ]>atiL'nt  l>c  |)jarc;d_  inhcHl  ;  and  in  Knirl:iii<l  it  is 
usual  lor  Ir'I-  to  lie  on  her  left^sulej  with  her  nates  paiallcl  to  the  od^e 
of  the  l)ed  and  her  body  lyiuj:;  across  it.  This  is  tlie  estal)li.shed  obstet- 
ric })osition  iu  Knjrlanil,  and  it  would  he  useless  to  attenij)t  to  insist  on 
any  other,  even  if  it  were  advisable.  Although  the  doi-sal  jMJsition  is 
preierred  on  the  Continent,  it  is  diificidt  to  see  wherein  its  a(lvanta<res 
cousist.  It  certaiidy  leads  to  unnecessary  exposure  of  tjie  pei-son,  and 
it  is,  on  the  whole,  less  easy  to  icacli  the  j)atient  so  })Iaced  i"or  the  neces- 
siuy  manipulations.  Moreover,  the  dorsal  position  increases  the  risk 
of  laceration  of  the  perineum  by  bringing  the  weight  of  the  child'.s 
head  to  bear  more  directly  upon  it.  Thus,  Schroeder  found  that  lacera- 
tions occurred  in  37.6  per  cent,  of  eases  delivered  on  the  back,  as  against 
24.4  per  cent,  in  other  ))ositions. 

The  patient  usually  remains  in  bed  during  the  whole  of  this  stage, 
and  it  is  customary  for  the  nurse  to  tie  to  the  foot  of  the  bod  a  jack- 
towel,  Avhicli  is  laid  hold  of  and  used  as  a  support  in  making  bearing- 
down  eiforts.  If  the  pains  be  few  and  far  between,  and  the  patient 
finds  it  more  comfortable  to  get  up  occasionally,  there  is  no  reason  why 
she  should  not  do  so.  On  the  contrary,  as  we  shall  subsequently  see  in 
treating  of  lingering  labor,  the  pains  under  such  circumstances  are  often 
increased  in  the  sitting  posture  in  consequence  of  fiie  Aveight  of  the 
child  ])roducing  increased  pressure  on  the  nerves  of  the  vagina. 

At  this  time  vaginal  examination,  \vhich  should  be  more  frequently 
repeated  than  in  the  first  stage,  enables  us  to  ascertain  precisely  the 
position  of  the  head  l)y  means  of  the  sutures  and  fontanel les,  as  well 
as  to  watch  its  i)rogress. 

( It  not  unfrequently  happens  that  the  head  descends  into  the  pelvis, 
even  to  its  floor,  without  the  os  having  entirely  disappeared.  The  an- 
terior lip  especially  is  apt  to  get  caught  between  the  head  and  jnibes, 
to  become  swollen  by  the  pressure  to  which  it  is  subjected,  and  then  to 
retard  the  progress  of  the  labor.j  Thci'e  can  be  no  reasonable  objection 
to  attem])ting  to  prevent  this  cause  of  delay  by  pressing  on  the  incar- 
cerated lip  during  the  interval  of  the  pains,  so  as  to  ])ush  it  above  the 
head  and  maintain  it  there  during  the  pains  until  the  head  descends 
below  it.  This  manoeuvre,  if  done  judiciously  aud  without  any  undue 
roughness  or  force,  is  certainly  not  liable  to  be  attended  by  any  of  the 
evil  consequences  which  many  obstetricians  have  attributed  to  it;  it  is 
indeed  a  matter  of  common  sense  that  the  injiny  to  the  cervix  is  likely 
to  be  less  if  it  be  pushed  gently  out  of  the  way  than  if  it  be  left  to  be 
tightly  jammed  for  hours  between  the  j>resenting  part  and  the  bony 
pelvis.  This  mode  of  assistance  is  very  different  from  the  digital  dila- 
tation of  a  rigid  cervix,  which  was  formerly  much  jmtctised,  especially 
in  Edinl)urgh,  in  consef|uence  of  the  recommendation  of  Hamilton,  and 
which  was  projK'rly  oljjected  to  l)y  the  great  majority  of  oltstctricians. 

li'  the  pains  be  ]iroducing  satisfactory  ])rogress,  no  further  interfer- 
ence is  required,  /'  The  medical  attendant  should,  however,  see  that  the 
bladder  is  evacuated,  and  if  it  have  not  been  so  for  sonic  hours  it 
may  be  necessary  to  draw  off  the  urine  by  the  catheter,  ^^'llenever 
the   labor  is  lengthy   he  should  occasionally  practise  auscultation,  so 


MANAGEMENT  OE  NATURAL  LABOR.  291 

as  to  satisfy  liiinsc]!'  tliat   the  i\vAii\    circiilatioii    is  hciii}^  salisfactorilv 
carried  on. 

The  regulation  of  the  bearing-down  eiibrts  at  this  time  is  of  import-' 
ance.  It  is  common  for  the  nurse  to  urge  the  patient  to  lielj)  lierself 
by  straining,  and  it  is  certain  tliat  by  vohintary  action  of  this  kind  she 
can  materially  increa-se  the  action  of  the  accessory  muscles  of  parturi- 
tion. If  the  pains  be  strong  and  the  labor  promise  to  1)C  rapid,  such 
voluntary  exertions  are  not  likely  to  be  prejudicial.  On  the  other  hand, 
if  the  case  be  progressing  slowly,  they  ouh^  unnecessarily  fatigue  the 
})atient,  and  should  be  discouraged.  When  the  perineum  is  distended 
Me  may  even  find  it  advisable  to  urge  the  patient  to  cease  all  voluntary 
eifort  and  to  cry  out,  for  the  express  purpose  of  lessening  the  tension  to 
which  the  perineum  is  subjected.  This  is  the  stage  in  which  anaesthesia 
is  most  serviceable,  but  its  employment  nmst  be  separately  discussed. 

Distension  of  the  Perineum. — As  the  head  descends  more  and  more 
the  perineum  becomes  distended,  and  there  is  considerable  difference  of 
opinion  amongst  accoucheurs  as  to  the  management  of  the  case  at  this 
time.  In  most  obstetric  works  the  practitioner  is  advised  to  endeavor 
to  prevent  laceration  by  the  manreuvre  that  is  described  as  "  supp^ortlng 
the  perineum."  vBy  this  is  meant  laying  the  palm  of  the  hand  on  the 
distended  structures  and  pressing  firmly  upon  them  during  the  acme 
of  the  pain,  with  the  view  of  mechanically  ])reveuting  their  tearing.) 
There  can  be  little  doubt  that  this  or  some  modification  of  it  is  the 
practice  now  followed  by  the  large  majority  of  practitioners.  Of  late 
years  the  evil  effects  likely  to  follow  it  have  been  specially  dwelt  upon 
by  Graily  Hewitt,  Leishman,  Goodell,  and  other  writers,  who  maintain 
that  by  pressure  exerted  in  this  fashion  we  not  only  fail  to  prevent,  but 
actually  favor,  laceration,  in  consequence  of  the  pressure  joroducing 
increased  uterine  action  just  at  the  time  when  forcible  distension  of  the 
perineum  is  likely  to  be  hurtful.  Therefore  some  hold  that  the  peri- 
neum ought  to  be  left  entirely  alone,  and  that  the  head  should  be  allowed 
gradually  to  distend  it,  without  any  assistance  on  the  part  of  the  prac- 
titioner. 

Much  error  may  be  traced  to  a  misconception  of  ^hat  is  required. 
The  term  "  supporting  the  perineum  "  conveys  an  unquestionably  erro- 
neous idea,  and  it  is  certain  that  no  one  can  prevent  laceration  by 
Jiiechanical  support.  If  the  term  "  relaxation  of  the  perineum  "  was 
employed,  we  should  have  had  a  fiir  more  accurate  idea  of  what  should 
be  aimed  at,  and  if  this  be  borne  in  mind  I  think  it  cannot  be  ques- 
tioned that  nature  may  be  most  usefully  assisted  at  this  stage. 

Dr.  Goodell  of  Philadelphia  has  specially  studied  this  subject,  and 
has  recommended  a  method  the  object  of  which  is  to  relax  the  per- 
ineum, (  His  advice  is  that  one  or  two  fingers  of  the  left  hand  should 
be  inserted  intojh^rectuni,  by  which  the  perineum  should  be  hooked  up 
and  pulled  forward  over  the  head,  toward  the  pubcs,  the  thumb  of 
the  same  hand  being  placed  on  the  advancing  head,  so  as  to  restrain 
its  progress  if  needful.\  I  have  adopted  this  plan  frequently,  and 
believe  that  it  admiraoly  answers  its  purpose,  especially  when  the 
perineum  is  greatly  distended  and  la(«ratiou  is  threatened.  It  nuist 
be  admitted  that  the  insertion  of  the  fino-ers  into  the  anal  orifice  in 


2ii2 


LABOR. 


titinner  must  aim  at.   | 
greatly,  the  tlmiul)  aiui 


(the  iiiamier  recnnimeiuled  is  rcpiij^iiant  hotli  to  llie  i»i"actitii»iier  ami 
the  patient,  ami  the  same  result  can  be  obtained  in  a  less  unj)lcas- 
ant  wav.  I  mention  it,  however,  to  show  what  it  is  that  the  ))rae- 
If",  when  the  head  is  distending  the  perineum 
greariv,  tne  iimmi)  luui  forefinger  of"  the  right  hand  an;  j)laeed  along 
its  sides,  it  can  be  pushed  gently  forward  over  the  head  at  the  height 
of  the  pain,  while  the  tips  of"  the  fingers  may,  at  the  same  time, 
press  upon  the  advancing  vertex,  so  as  to  retard  its  progress  if  advisable  \ 
(Fig.  108).     By  this  means  the  sudden   and    forcible   stretching   of  ^^ 

Fig.  108. 


Mode  of  effecting  Relaxation  of  the  Perineum. 

the  perineal  structures  is  prevented  and  the  chance  of  laceration 
reduced  to  a  minimum,  while  nature's  mode  of  relaxing  the  tissues 
by  dilatation  of  the  anal  orifice  is  favored.  This  is  very  different 
fr6m  the  mechanical  support  that  is  usually  recommended,  and  the 
less  pressure  that  is  applied  directly  to  the  perineum  the  l)etter.  Nor 
is  it  either  needful  or  advisable  to  sit  by  the  patient  with  the  hand 
applied  to  the  perineum  for  lioin's,  as  is  so  often  practised.  Time 
should  be  given  for  the  gradual  distension  of  the  tissues  by  the  alter- 
nate advance  and  recession  of  the  head,  and  we  need  only  intervene 
to  assist  relaxation  when  the  stretching  has  reached  its  height  and 
the  head  is  about  to  be  expelled.  pV  na])kin  may  be  interposed  between  , 
the  hand  and  the  skin  for  the  purpose  of  cleanliness.  Should  the  \ 
perineum  be  excessively  tough  and  resistant,  assiduous  fomentation 
with  a  hot  sponge  may  be  resorted  to,  and  Avill  be  of  some  service 
in  promoting  relaxation. 

Incision  of  the  Perineum. — [When  the  tension  is  so  great  that 
laceration  seems  inevitable  it  is  generally  recommended  that  a  slight 
incision  should  be  made  on  each  side  of  the  central  raphe,  with  the 
view  of  preventing    spontaneous  laceration. ^  This  may  no  doubt  be 


MANAGEMENT  OE  NATURAL   LABOR.  293 

<loiic  witli  perlect  safety,  lnit,y  question  it'  it  is  likely  to  be  of  use. 
The  idea  is  that  an  ineiscd  \v6und  is  likely  to  heal  more  readily  than 
a  lacerated  one.  When,  liowever,  a  distended  perineum  ruptures,  its 
struotures  are  so  thinned  that  the  tear  is  always  linear,  and  as  a 
matter  of  fact  the  edges  of  the  tear  are  always  as  elean  ami  as  closely 
in  apposition  as  if  the  cut  had  been  made  with  a  knife.  l]\roreover, 
the  laceration  invariably  heals  perfectly  if  only  the  edges  be  brought 
into  contact  at  once  with  one  or  two  metallic  sutures.  (l  believe, 
therefore,  that  Goodell  is  right  in  stating  that  incision  oi  the  peri- 
neum is  rarely  if  ever  necessary,  unless  it  is  hardened  by  previous 
cicatrization]  In  almost  all  first  labors  the  fourchette  is  torn,  but 
requires  no_  treatment  of  any  kind.  In  some  cases,  do  what  we  will, 
more  or  less  laceration  occurs,  and  the  perineum  should  always  be 
examined  after  the  expulsion  of  the  child  to  see  if  any  tear  has  taken 
place. 
/  If  it  has  given  way  to  any  extent,  I  believe  that  it  is  good  prac- 
tice to  insert  oue  or  two  interrupted  sutures  of  silver  wire  or  car- 
'■  bolized  gut  at  once.  J  Immediately  after  delivery  the  sensibility  of  the 
tissues  is  deadened  by  the  distension  to  which  they  have  been  sub- 
jected^ ^d  the  sutures  can  be  inserted  with  little  or  no  pain.  It 
is  quite  true  that  lacerations  of  an  inch  or  less  will  generally  heal 
perfectly  well  of  themselves  ;  but  this  is  not  invariably  the  case,  while 
healing  almost  certainly  follows  if  the  edges  be  brought  together  at 
once.  In  the  severer  forms  of  laceration,  extending  back  to,  or  even 
through,  the  sphincter,  the  precaution  is  all  the  more  necessary,  and  a 
subsequent  more  serious  operation  may  in  this  way  be  avoided.  The 
sutures  can  be  removed  without  difficulty  in  a  week  or  so,  when  com- 
plete adhesion  has  taken  place. 

Expulsion  of  the  Child. — The  head,  when  expelled,  should  be' 
received  in  the  palm  of  the  right  hand,  while  the  left  hand  is  placed 
upon  the  abdomen  to  follow  down  the  uterus  as  it  contracts  and  expels 
the  body.  There  is  generally  some  little  delay  after  the  expulsion  of 
the  head,  and  we  should  now  see  if  the  cord  surround  the  neck,  and  if 
it  does  so  it  should  be  drawn  over  the  head,  and,  if  this  is  not  possible, 
it  may  be  tied  and  divided  between  the  ligatures.  (  The  expulsion  of 
the  body  should  be  left  entirely  to  the  uterine  contractions,'  If  there 
be  undue  delay,  we  may  endeavor  to  excite  uterine  action  by  friction 
on  the  fundus,  and  it  will  rarely  happen  that  sufficient  contraction  does 
not  now  come  on.  If  we  display  undue  haste  in  withdrawing  the 
body,  we  run  the  risk  of  emptying  the  uterus  while  its  tissues  are 
relaxed,  and  so  ftwor  hemorrhage.  If,  however,  there  seem  serious 
danger  of  the  child  being  asphyxiated,  its  expulsion  may  be  favored 
by  gently  passing  the  forefinger  of  each  hand  within  the  axilla?  and 
using  traction ;  but  it  is  only  very  exceptionally  that  such  interference 
is  required. 

Promotion  of  Uterine  Contraction  after  the  Birth  of  the  Child. 
— ^..Vs  the  uterus  contracts  it  should  be  carefully  followed  down  through 
the  abdominal  parietcs  by  the  left  hand,  which  should  grasp  it  as  the 
body  is  expelled,  with  the  view  of  seeing  that  it  is  efficiently  contracted.) 


294  LABOR. 

This  is  ;i  point  of  vital    iinj)ortaii('(»   in   j)i'('V('ntiii!^    Iicinonliauc,  wliii-li 
will  })rcseiitly  1)0  more    especially  considered. 

(^As  soon  as  the  child  cries  we  may  proceed  to  tie  and  sej)ai-ate  the  cord.^ 
For  this  pnrpose  the  luirse  nsnallv  provides  liii;atures  coni|)o<ed  of  sev- 
eral strands  of"  whitey-hrown  tlii'cad,  but  tape  or  any  other  snitahle 
material  muy  be?  employed.  It  is  important,  especially  ii"  the  cord  be 
very  thick  and  ^ijelatinous,  to  see  that  it  is  tlior<ni<j;ldy  compressed,  so 
that  the  vessels  are  obliterated,  otherwise  secondary  iiemorrha(>;e  miuht 
occnr.  The  cord  is  tied  abont  an  inch  and  a  half"  from  the  child,  and 
it  is  usual — though,  of  course,  not  essential — to  place  a  second  lig'ature 
about  two  inches  nearer  the  placental  extremity  t)f  the  cord.  The  latter 
is  ])erhaps  of  some  use  by  retainin<r  tlie  blood,  and  thus  increasintr  the 
size  of  the  placenta  and  favoring  its  more  ready  expulsion  by  uterine 
contraction.  The  cord  is  then  divided  with  scissors  between  the  liga- 
tures, the  child  wrap])cd  up  in  flannel  and  given  to  the  nurse  or  to  a 
bystander  to  hold,  while  the  attention  of  the  j)ractitioner  is  concentrated 
on  the  tiiother,  with  a  view  to  the  proper  management  of  the  third 
stage  of  labor.  The  researches  of  Budin,'  Ribemont,^  and  others  show 
that  there  is  a  distinct  advantage  in  not  tying  the  cord  until  the  child 
has  cried  lustily,  as  the  act  of  respiration  tends  to  withdraw  the  placen- 
tal blood,  and  thus  increases  the  entire  amount  of  blood  in  the  foetus. 
It  is  said  that  after  late  ligature  of  the  cord  the  child  is  more  vigorous 
and  active  than  when   it  is  tied  too  early. 

*  The  cord  may,  if  preferred,  be  treated  with  perfect  safety  by  lacera- 
tion.|  This  method  was  first  brought  under  my  notice  by  my  friend  Dr. 
Stejmen,  who  has  employed  it  for  many  years  and  in  several  hundred 
cases.  The  cord  is  twisted  round  the  index  fingers  of  both  hands  and 
torn  through,  the  lacerated  vessels  retracting  without  any  hemorrhage. 
It  is  a  close  imitation  of  the  method  instinctively  adopted  by  the  lower 
animals,  who  gnaw  the  cord  asunder,  and  has  the  advantage  of  dis- 
pensing with  ligatures  altogether.  I  have  used  it  myself  in  a  large 
number  of  cases,  but  prefer,  on  the  whole,  the  plan  usually  adopted. 
Importance  of  Proper  Management  of  Third  Stage. — There  is 
unquestionably  no  period  of  lal)or  where  skilled  management  is  more 
im[)ortant,  and  none  in  which  mistakes  are  more  frequently  made.  By 
proper  care  at  this  time  the  risk  of  post-partum  hemorrhage  is  reduced 
to  a  minimum,  the  efficient  contraction  of  the  uterus  is  secured,  tlie 
amount  and  intensity  of  after-pains  are  lessened,  and  the  safety  and 
comfort  of  the  patient  greatly  promoted.  INForeover,  the  general  ]>rac- 
tice  as  to  the  management  of  this  stage  is  opposed  to  the  natural  mei-han- 
ism  of  placental  ex])ulsion,  and  is  far  from  being  well  adapted  to  secure 
the  im})ortant  objects  which  we  ought  to  have  in  view.  Let  us  see  what 
is  the  practice  usually  recommended  and  followed,  and  then  we  shall  be 
in  a  ]K)sition  to  understand  in  what  respects  it  is  erroneous.  For  this 
j)ur[)ose  I  cannot  do  l)etter  than  copy  the  directions  contained  in  one  of 
our  most  deservedly  popular  obstetric  textbooks,  which  inidoubtedly 
expresses  the  usual  ])ractice  in  the  management  of  this  stage :  "  ^^  hen 
the  binder  is  applied  the  patient  may  be  allowed  to  rest  a  while  if  there 

'  BiiHin,  Profffh  medicfil.  1876.  toiii.  iv.  pp.  2,  3G. 
^Archil:  de  Tocologie,  1879,  p.  577. 


MANAGEMENT  OF  NATURAL  LABOR.  295 

is  no  flooding;  after  wlilcli,  ir/icn  the  idrrus  contraHs^  gv.uth'.  traction 
may  l)e  made  by  the  funis  to  ascertain  if  the  placenta  he  detached.  If 
so,  and  especially  if  it  be  in  tlie  vagina,  it  may  be  removed  by  continu- 
ing the  traction  steadily  in  the  axis  of  the  upper  outlet  at  first,  at  the 
same  time  making  pressure  on  the  uterus."  ' 

[In  this  country,  for  many  years,  the  uniform  teaching  has  been  that 
the  binder  should  not  be  applied  until  the  uterus  has  expelled  the  pla- 
centa and  become  lirmly  contracted.^  Although  the  plan  of  expression 
was  not  carried  out  as  completely  as  is  noAv  taught  under  the  Crede 
method,  that  of  stimulating  the  contractions  of  the  uterus  by  manipula- 
tion and  pressure  was  certainly  in  use  forty  years  ago.  When  the  size 
and  solidity  of  the  uterus,  as  ascertained  by  the  compressing  hand,  indi- 
cate that  the  placenta  has  been  expelled  into  the  vagina,  it  is  a  question 
whether  we  shall  cause  it  to  be  forced  through  the  vulva  by  pressing 
down  the  uterus  upon  it,  or  make  traction  upon  it  by  the  finger  hooking 
down  its  edge.  Occasionally,  we  find  a  patient  who  is  very  sensitive  to 
pressure  made  upon  her  uterus  after  it  has  become  firmly  contracted ; 
and  in  such  a  case  it  may  be  well  to  depend  partly  upon  traction  for 
completing  the  delivery  of  the  secundines.  That  it  is  possible  for  the 
uterus  to  expel  the  placenta  suddenly  from  the  vagina  where  no  pressure 
has  been  made  is  evident  from  the  fact  that  a  physician  of  this  city,  who 
was  making  traction  upon  the  cord  under  the  old  method  some  vears 
ago,  was  surprised  to  find  the  placenta  shoot  out  from  the  vulva  and 
dangle  by  the  funis  as  he  held  it  in  his  hand.  In  such  a  case  the  uterus, 
must  have  been  aided  during  a  contraction  by  voluntary  abdominal 
pressure,  causing  the  os  to  descend  nearly  to  the  vulva.  It  is  very  evi- 
dent that  the  uterus  is  subject  to  muscular  fatigue  and  to  the  exhaustion 
of  its  contractile  power  Mhen  long  in  action ;  hence  there  is  a  greater 
risk  of  uterine  atony  and  hemorrhage  after  a  long  labor  than  a  short 
one,  and  we  may  expect  a  more  complete  expulsion  of  the  placenta  in 
the  latter.  It  is  also  clear,  from  cases  in  my  own  experience,  that  the 
muscular  power  of  the  uterus  is  by  no  means  in  proportion  to  the  gen- 
eral strength  of  the  woman.  The  power  to  assist  by  bearing  down  no 
doubt  is,  but  the  independent  power  of  the  organ  itself  does  not  appear 
to  be.  Certainly  some  of  the  most  perfect  in  parturient  power  that 
have  come  under  my  care  were  small  women  with  little  general  nuis- 
cular  force.  One  little  woman  of  86  pounds  weight  appeared  almost 
to  have  escaped  the  curse  pronounced  upon  Eve ;  and  another,  still 
smaller,  expelled  a  placenta  from  her  vagina  almost  M'ithout  any  loss 
of  blood. — Ed.] 

This  may  fairly  be  taken  as  a  sufficiently  accurate  description  of  the 
practice  usually  followed.  The  objections  I  have  to  make  are:  (1) 
That  it  inculcates  the  common  error  of  relying  on  the  binder  as  a  means  i 
of  promoting  uterine  contraction,  advising  its  apj)lication  before  the 
expulsion  of  the  placenta,  while  I  hold  that  the  binder  should  never  be  I 
applied  until  after  the  placenta  is  expelled,  and  not  even  then  unless  the 
uterus  is  perfectly  and  permanently  contracted.  (2)  That  it  teaches  that 
traction  on  the  cord  should  be  used  as  a  means  of  withdrawing  the  pla-. 
centa;  whereas /the  uterus  itself  should  be  made  to  expel  the  after-birth,/ 

'  ChurohiU's  Tlwonj  and  Practice  of  Mkhcij'enj,  p.  162. 


29() 


LAliOlt. 


aii<l  ill  iiiiu'tccii  cases  out  of"  twenty  the  liiij^i'i"  need  never  l»e  intnttlneed 
into  the  vagina  after  the  birtli  of  the  child,  nor  the  cord  touclied.  'J'his 
may  seem  an  exaj:;«»erated  statement  to  those  who  have  accustomed 
themselves  to  the  usual  method  of  dealing  with  the  placenta,  but  I  feel 
confident  that  all  mIio  have  learnt  the  method  of  expressiou  of  the 
j)lacenta   woidd   testify  to  its  accuracy.' 

Expression  of  the  Placenta:  its  Object. — 'i'he  cardinal  point  to 
bear  in  mintl  is,  that  the  placenta  should  be  expelled  from  the  uterus  by 
a  I'is  a  iergo,  not  drawn  out  by  Si  vis  a  f route.  That  uterine  pressure 
after  the  birth  of  the  child  has  been  recommended  l)v  many  English 
writers  is  certain,  and  the  Dublin  school  especially  have  dwelt  on  its 
importance  as  a  jireventive  of  ])ost-]wrtnm  hemori'liage  ;  but  the  distinct 
enunciation  of  the  doctrine  that  the  placenta  should  be  ])ressed,  and 
not  drawn,  out  of  the  uterus,  we  owe  to  Crede  and  other  German 
writers,  and  it  is  only  of  late  years  that  this  practice  has  become  at  all 
connnou.  Those  who  have  not  seen  placental  expression  practised  find 
it  difficult  to  understand  that  in  the  large  majority  of  cases  the  uterus 
may  be  made  to  expel  the  placenta  out  of  the  vagina  ;  but  such  is 
unquestionably  the  fact.  A  little  practice  is  no  doul)t  necessary  to  effect 
this  satisfactorily,  but  when  once  the  knack  has  been  learnt  there  is  little 
difficulty  likely  to  be  experienced. 

Before  describing  the  method  of  placental  expression  a  word  of  cau- 
tion may  be  said  against  undue  haste  in  attempting  expression  of  the 
•])lacenta — a  mistake  that  is  often  made,  and  which,  I  believe,  tends  to 
increase  the  risk  of  post-partum  hemorrhage.  \^8o  long  as  we  satisfy 
ourselves  that  the  uterus  is  fairly  contracted,  so  as  to  avoid  the  possi- 

'  This  practice  is  further  ilhistrated  by  the  annexed  diagram,  contained  in  most 

Fig  109. 


Usual  Method  of  Removing  the  Placenta  by  Traction  on  the  Cord, 
obstetric  works,  whicli  represents  the  accoucheur  as  withdrawing  the  pUicenta  by  trac- 
tion, and  which  I  insert  as  an  ilkistration  of  what  ought  nol  to  be  done  (Fig.  109). 


MANAGEMENT  OF  NATURAL  LABOR. 


297 


bility  of  its  distension  with  blood,  a  certain  delay  after  the  birth  of  the 
child  is  useful,  from  its  giving  time  for  coagula  to  form  within  the 
uterine  sinuses  by  which  their  oj)en  mouths  are  closed  j  The  importance 
of  this  point  has  been  specially  dwelt  upon  by  McUlintock,  who  lays 
down  the  rule  that  lifteen  or  twenty  minutes  should  be  allowed  to  elapse 
after  the  birth  of  the  child  before  any  attempt  to  remove  the  after-birth 
is  made.  This  is  a  good  and  safe  practical  rule,  as  it  gives  ample  time 
for  the  complete  detachment  of  the  placenta  and  the  coagulation  of  the 
blood  in  the  uterine  sinuses. 

During  tliis  interval  the  practitioner  or  nurse  should  sit  by  the  bed- 
side, with  the  hand  on  the  uterus  to  secure  contraction  and  prevent  dis- 
tension, but  not  kneading  or  forcibly  compressing  it.  When  we  judge 
that  a  sufficient  time  has  elapsed  \ve  may  proceed  to  effect  expulsion. 
For  this  purpose  the  fundus  should  be  grasped  in  the  hollow  of  the  left 
hand,  the  ulnar  edge  of  the  hand  being  well  pressed  down  behind  the 
fundus,  and  ivhen  the  uterus  is  felt  to  harden  strong  and  firm  pressure 
should  be  made  downward  and  backward  in  the  axis  of  the  pelvic  brim. 
If  this  manoeuvre  be  properly  carried  out  and  sufficiently  firm  pressure 
made,  in  almost  every  case  the  uterus  may  be  made  to  expel  the  placenta 
into  the  bed,  along  with  any  coagula  that  may  be  in  its  cavity  (Fig. 
110).    [  The  uterine  surface  of  the  placenta  is  generally  expelled  first,  as 

Fig.  110. 


illustrating  Expression  of  the  Placeuta. 

is  represented  in  the  diagram,  the  cord  being  within  the  membranes] 
whereas  the  foetal  surface  and  root  of  the  cord  are  the  parts  Avhich  appear 
first  when  the  placenta  is  removed  by  traction  (Fig.  109).  ilf  we  do  not 
succeed  at  the  first  effort — which  is  rarely  the  case  if  extrusion  be  not 
attempted  too  soon  after  the  birth  of  the  child — we  may  wait  until 
another  contraction  takes  place,  and  then  reajiply  the  pressure^  I  rejieat 
tliat  after  a  little  ])ractice  the  placenta  may  be  entirely  expelled  in  this 
way  in  nineteen  cases  out  of  twenty,  without  even  touching  the  cord,  and 
the  bugbear  of  retained  placenta  will  cease  to  be  a  source  of  dread. 


21»S  LABOR. 

\Sli(nil(l  we  fiiil  ill  caiisiiiL:,  the  uterus  to  ('.\])(l  the  ])l;ic<'ut:i,  :i  Viij^iual 
exaniiuation  may  he  luadi',  and  if"  the  placenta  he  found  lyiufjf  entiivlv 
ill  tlie  vagina  it  may  be  earefully  w  itlidrawn.  If",  however,  tlie  cord 
can  be  traced  up  through  the  os,  showing  tliat  the  phicenta  is  still  with- 
in the  uterine  cavity,  we  imist  again  resort  to  ])ressure  to  eilect  its 
exj)uision,  and  not  to  attempt  to  withdraw  it  by  tractioir.  Such  cases 
mav  fairly  be  classed  as  retained  placenta,  but  they  should  be  very 
rarely  met  with,  and  are  discussed  elsewhere.  ^^  hen  they  do  occur 
often  in  the  hands  of  the  same  practitioner,  it  is  iair  to  conclude  that 
he  has  not  properly  acquired  the  art  of  managing  this  stage  of  labor, 
(ienerally  speaking,  the  placenta  should  be  expelled  within  twenty 
minutes  after  the  birth  of  the  child,  but  no  doubt  in  the  large  majority 
of  cases  expulsion  might  be  effected  sooner  were  it  advisable;  to  attempt  it. 

Management  of  the  Membranes. — \Vhen  the  mass  of  the  placenta 
is  expelled  the  mendjranes  generally  still  remain  in  the  vagina,  and  they 
should  be  twisted  into  a  rope  and  ve^  gently  withdrawn,  so  as  not  to 
leave  any  j)ortion  behind^  This  is  a  jirecaution  the  importance^of 
which  I  would  strongly  urge,  for  I  believe  that  the  chance  of  part  of 
the  membranes  being  torn  off  and  left  in  utero  is  the  one  objection  to 
the  method  recommended.  W^ith  due  care,  however,  this  accident  may 
be  avoided,  and  the  risk  will  be  lessened  if  the  placenta  is  received  into 
the  palm  of  the  right  hand  on  expression,  so  as  to  avoid  any  strain  ou 
the  membranes. 

The  duties  of  the  medical  attendant  are  not  even  now  over.  For  at 
least  ten  minutes  after  the  extrusion  of  the  placenta  he  shoidd  keep  his 
hand  on  the  firmly-contracted  uterus,  gently  kneading  it,  without  any 
force,  for  the  purjiose  of  promoting  firm  and  equable  contraction  and 
causing  it  to  throw  off  the  coagula  that  may  form  in  its  cavity. 

\Xhe  subsequent  comfort  and  safety  of  the  patient  may  be  promoted 
by  administering  at  this  time  a  full  dose  of  ergot  of  r>e,  such  as  a 
drachm  or  more  of  the  liquid  extract. \  The  ])ro])erty  jiossessed  by  this 
drug  of  producing  tonic  and  persistent  contraction  of  tlie  uterine  fibres, 
which  renders  it  of  doubtful  utility  as  an  oxytocic  during  labor,  is 
of  s'^iecial  value  after  delivery,  when  such  contraction  is  jirecisely  what 
we  desire.  I  have  long  been  in  the  habit  oi'  administering  the  drug  at 
this  period,  and  believe  it  to  be  of  great  value,  not  only  as  a  j)rophy- 
lactic  against  hemorrhage,  but  as  a  means  of  lessening  al'ter-pains. 

Application  of  the  Binder.— ^When  we  are  satisfied  that  the  uterus 
is  ])ermanently  contracted  we  may  apjdy  the  binder,  but  this  should 
rarely  be  done  until  at  least  half  an  hour  after  the  birth  of  tlie^child. 
The  soiled  clothes  should  be  gently  withdraMii  from  under  the  jiatient, 
moving  her  as  little  as  jiossible,  and  the  binder  should  be  at  the  same 
time  sli])ped  under  the  body,  taking  care  that  it  is  ]iassed  wvW  below 
the  hij)s,  so  as  to  secure  a  firm  hold.  Xo  kind  of  l)andagc  is  better  than 
a  piece  of  stout  jean  of  sufficient  breadth  to  extend  from  the  trochanters 
to  the  ensiform  cartilage  ;  a  jack-towel  or  bolster  slip  answei*s  the  ])ur- 
])Ose  very  well.  These  are  preferable,  at  any  rate  at  first,  to  the  sha]>ed 
binders  that  are  often  used.  One  or  two  folded  na})kins  are  generally 
})laced  over  the  uterus,  so  as  to  form  a  ])ad  to  keep  up  ])ressure.  Once 
in  position,  the  binder  is  pulled  tight  and  fiistcni'd  by  pins.     The  utility 


ANJESTHESIA   IN  LABOR.  299 

of  careful  bandaginj^  al'tcr  delivery  can  scarcely  be  doubted,  altiiough 
some  years  ago  it  became  the  liisliiou  to  dispense  with  it.  It  gives  a 
comfortable  support  to  the  lax  abdominal  walls,  keeps  up  a  certain 
amount  of  pressure  on  the  uterus,  and  tends  to  restore  the  figure  of 
the  j)atient.  /After  the  bandage  is  applied  a  warm  napkin  should  be 
placed  on  the  vulva,  as  a  means  of  estimating  the  quantity  of"  tlie  dis- 
charge, andT  tli(r|)atient  may  be  allowed  to  rest. 

After-treatment. — Unless  the  labor  has  been  very  long  and  fatigu- 
ing an  opiate,  often  exhibited  as  a  matter  of  routine,  is  unadvisable, 
although  it  may  be  well  to  leave  one  with  the  nurse,  to  be  given  if  the 
])aticnt  cannot  sleep  or  if  the  after-pains  be  very  troublesome.  'The 
practitioner  may  now  leave  the  room,  but  not  the  house,  and  at  least 
an  hour  should  elapse  after  delivery  before  he  takes  his  departure.'^ 
Before  doing  so  he  should  visit  the  patient,  inspect  the  napkin  to  see 
that  there  is  not  too  much  discharge,  and  satisfy  himself  that  the  uterus 
is  contracted  and  not  distended  with  coagula.  He  should  also  count  the 
pulse,  which,  if  the  patient  be  progressing  satisfactorily,  will  be  found 
at  its  normal  average.  If,  however,  it  be  beating  over  one  hundred  per 
minute,  he  should  on  no  account  leave,  for  such  a  rapidity  of  the  cir- 
culation renders  it  extremely  probable  that  hemorrhage  is  impending. 
This  is  a  good  practical  rule,  laid  down  by  McClintock  in  his  excellent 
paper  On  the  Pulse  in  Childbed,  attention  to  which  may  often  save  the 
patient  from  disastrous  consequences. 

Before  leaving  the  practitioner  should  see  that  the  room  is  darkened, 
all  bystanders  excluded,  and  the  patient  left  as  quiet  as  possible  to 
recover  from  the  shock  of  labor. 


CHAPTER    IV. 

ANESTHESIA    IN    LABOK. 

A  FEW  words  may  be  said  as  to  the  use  of  anaesthetics  during  labor — 
a  practice  which  has  become  so  universal  that  no  argument  is  required 
to  establish  its  being  a  perfectly  legitimate  means  of  assuaging  the  suf- 
ferings of  childbirth.  Indeed,  the  tendency  in  the  present  day  is  in  the 
Oj)posite  direction,  and  a  common  error  is  the  administration  of  chloro- 
form to  an  extent  which  materially  interferes  with  the  uterine  contrac- 
tions and  predisposes  to  subsecpient  post-])artum  hemorrhage. 

Agents  Employed — Practically  speaking,  the  only  agent  hitherto 
employed  in  England  is  chloroform,  although  the  bichloride  _of 
methylene  and  ether  have  been  occasionally  tried.  Of  late  years 
chloral  has  been  extensively  used  by  some,  and,  as  I  believe  it  to  be 
an  agent  of  very  great  value,  I  shall  tirst  indicate  the  circumstances 
under  which  it  may  be  employed. 


300  LABOR. 

The  pcouliar  vmIuo  of  cliloral  in  labor  is  that  it  maybe  safely  atlniin- 
istered  at  a  time  when  chlorotoi-ni  cannot  be  <i<'n('rally  employed.  1'he 
latter,  while  it  annuls  sulU'ring,  very  frequently  tends  in  a  marked 
dej^rce  to  diminish  uterine  action.  This  is  a  familiar  observation  to 
all  who  have  emj)loved  it  much  durinj;  labor,  as  the  diminution  of  the 
force  and  intensity  of  the  ])ains,  and  the  consequent  ri'tai<hition  oi'  the 
labor,  often  oblige  us  to  susjx'nd  its  inhalation,  at  least  temporarily. 
Indeed,  this  very  ])roperty  ol'  annulling'  uterine  action  is  one  of  its 
most  valuable  qualities  in  obstetrics,  as  in  certain  cases  of  turning. 
For  such  purposes  it  is  uecessary  to  give  it  to  the  surgical  extent, 
M'liich  we  endeavor  to  avoid  when  it  is  used  simply  to  le&sen  the  suf- 
fering of  ordinary  labor.  Still,  it  is  not  always  easy  to  limit  its  action 
in  this  way,  and  thus  it  very  frequently  does  more  than  we  wish.  Such 
diminution  in  the  intensity  of  uterine  contraction  is  comparatively  of 
less  couse([uence  in  the  propulsive  stage,  and  it  is  generally  more  than 
counterbalanced  by  the  relief  it  affords, ('In  the  first  stage  it  is  other- 1 
wise,  and,  practically  speaking,  chloroform  is  generally  not  admissible! 
until  the  head  is  in  the  pelvic  cavity. \ 

(  Chloi-al,  on  the  other  hand,  has  no  such  relaxing  eflects  on  uterine  con- 
traction.) It  cannot,  it  is  true,  compete  with  chloroform  in  its  power  of 
relieving  })aiu,  but  it  ])roduces  a  droAvsy  state  in  which  the  pain  is  not 
felt  nearly  so  acutely  as  before.  It  is  therefore  in  the  first  statye  of 
labor,  W'hile  the  pains  are  cutting  and  grinding,  and  during  the  dilata- 
tion of  the  cervix,  that  it  finds  its  most  useful  ap])lication.  It  is 
especially  valuable  in  those  cases,  so  frequently  met  with  in  the  up])er 
classes,  in  which  the  pains  produce  intolerably  acute  sufl'ering,  but  with 
little  eff(2ct  on  the  progress  of  the  labor.  In  them  the  os  is  often  thiu 
and  rigid  and  the  pains  very  frequent  and  acute,  but  little  or  no  dila- 
tation is  effected.  When  the  patient  is  brought  under  the  influence  of 
chloral,  however,  the  pains  become  less  frequent,  but  stronger,  nervous 
excitement  is  calmed,  and  the  dilatation  of  the  cervix  often  proceeds 
rapidly  and  satisfactorily.  Indeed,  I  know  of  nothing  which  answers 
so  well  in  cases  of  rigid,  undilatable  cervix,  and  I  believe  its  adminis- 
tration to  be  far  more  effective  under  such  circumstances  than  any  of 
the  remedies  usually  employed. 

The  object  is  to  j)roduce  a  somnolent  condition  which  shall  be  ]iro- 
tracted  as  long  as  possible.  (For  this  ])ur])ose  fifteen  grains  of  chloral 
may  be  administered  every  twenty  minutes  until  tiiree  (Toses  are  given. ^ 
This  generally  suffices  to  })r()duce  the  desired  effect.  The  patient  be- 
comes  very  drowsy,  dozes  between  the  pains,  and  wakes  up  as  each 
contraction  commences.  It  may  be  necessary  to  give  a  fourth  dose  at 
a  longer  interval,  say  an  hour  after  the  third  dose,  to  keep  up  and  pro- 
long the  so])()rific  action  ;  but  this  is  seldom  necessary,  and  I  have 
rarely  given  more  than  a  drachm  of  chloral  during  the  entire  j)rogress 
of  labor.  (  Another  advantage  of  this  treatment  is  that,  while  it  does 
not  interfere  with  the  use  of  chloroform  in  the  second  stage,  it  renders 
it  necessary  to  give  less  than  otherwise  would  be  called  for,  and  thus 
its  action  can  be  more  easily  kept  within  bounds.  \  On  the  whole,  there- 
fore, I  am  inclined  to  consider  chloral  a  very  valuable  aid  in  the  man- 
agement  of  labor,  and    believe  that   it   is  destined  to  be  much   more 


ANJESTHESIA  IN  LABOR.  301 

extensively  used  tliaii  is  at  present  the  case.  So  far  as  my  experience 
lias  yet  gone,  I  have  not  met  with  any  symptoms  wliieh  have  led  me 
to  think  that  it  has  produced  bad  efiects;  and  1  have  known  many 
patients  sleep  quietly  through  labor,  without  expressing  any  excessive 
sutfering  or  asking  for  chloroform,  who  under  ordinary  circumstances 
would  have  been  most  urgently  calling  for  relief.  It  occasionally  hap- 
pens that  the  patient  cannot  retain  the  chloral,  from  its  tendency  to  pro- 
duce sickness ;  it  may  then  be  readily  given  jjcr  recUim  in  the  form  of 
enema. 

i  Generally  speaking,  we  do  not  think  of  giving  chloroform  until  the 
OS  is  fully  dilated,  the  head  descending,  and  the  pains  becoming  pro- 
pulsive.ll  It  has  often,  indeed,  been  administered  earlier  for  the  purpose 
of  aiding  the  dilatation  of  a  rigid  cervix,  and  there  is  no  doubt  that  it 
often  succeeds  well  when  employed  in  this  way  ;  but  I  have  already 
stated  my  belief  that  chloral  answers  this  purpose  better. 

There  is  one  cardinal  rule  to  be  remembered  in  giving  chloroform 
during  the  propulsive  stage,  and  that  is  that  it  should  be  administered 
intermittently  and  never  continuously.  When  the  pain  comes  on  a  few 
drops  may  be  scattered  over  a  OKinner's  inhaler,  which  aifords  one  of 
the  best  means  of  administering  it  in  labor,  or  placed  within  the  folds 
of  a  handkerchief  twisted  into  the  form  of  a  cone.  During  the  acme  of 
the  pain  the  patient  inhales  it  freely,  and  at  once  experiences  a  sense 
of  great  relief;  and  as  soon  as  the  pain  dies  away  the  inhaler  should 
be  removed.  In  the  interval  between  the  pains  the  effect  of  the  drug 
passes  off,  so  that  the  higher  degree  of  aneesthesia  should  never  be  pro- 
duced. Indeed,  when  properly  given  consciousness  should  not  be 
entirely  abolished,  and  the  patient  between  the  pains  should  be  able  to 
speak  and  understand  what  is  said  to  her.  This  intermittent  adminis- 
tration constitutes  the  peculiar  safety  of  chloroform  administered  in 
labor,  and  it  is  a  fortunate  circumstance  that  as  yet  there  is,  I  believe, 
no  case  on  record  of  death  during  the  inhalation  of  chloroform  for 
obstetric  purposes.[']  This  is  obviously  due  to  the  effect  of  each  inhala- 
tion passing  off  before  a  fresh  dose  is  administered. 

The  effect  on  the  pains  should  be  carefully  watched.  If  they  become 
very  materially  lessened  in  force  and  frequency,  it  may  be  necessary  to 
stop  the  inhalation  for  a  short  time,  commencing  again  when  the  pains 
get  stronger  :•  this  effect  may  be  often  completely  and  easily  prevented 
by  mixing  the  chloroform  with  about  one-third  of  absolute  alcohol^ 
which,  originally  recommended,  I  believe,  by  Dr.  Sansom,  increases  the 
stimulating  effects  of  chloroform  and  thus  diminishes  its  tendency  to 
produce  undue  relaxation.  The  amount  administered  must  vary,  of 
course,  with  the  peculiarities  of  each  individual  case  and  the  effect 
])roduced,  but  it  need  never  be  large.  As  the  head  distends  the  peri- 
neum and  the  pains  get  very  strong  and  forcing,  it  mav  be  given  more 
freely  and  to  the  extent  of  inducing  even  complete  insensibility  just 
before  the  child  is  born. 

['  Prof.  Playfair  may  find  five  cases  of  cliloroform-poisoning  in  obstetrical  cases,  with 
two  deatlis,  reported  by  Prof  Lusk  in  the  Transaction!^  nf  the  Ainiyricnn  GunrrntcKjical 
Society  for  the  year  1877.  Three  of  the  patients  were  saved  through  artificial  respira- 
tion.— Ed.] 


302  LAB  on. 

Ether.— flu  cmscs  in  wliidi  ••liloioiui-iii  li:is  lessened  the  force  (if  llie 
])aiiis  etliiT  mny  he  j^iveii  iii>te;i(l  w  itii  !Lire:it  :i(lvaiita<i(',  ]  It  eertaiiilv 
(if'teii  aets  well  wIk'Ii  {■liloroioriii  is  inaihiiissihle  <»n  airoiiiil  ol"  its  elTects 
on  the  })ains,  and,  so  far  as  my  experieiiee  j2;oes,  it  lias  not  the  ])r(»j)erty 
of  relaxiu*!,-  the  iiteriisi,  Ijut,  on  the  eontrary,  has  soiiietiiues  seemed  to 
nie  distinctly  to  intensify  the  pains.  Of  late  I  have  used  a  mixture  of 
one  part  of  ahsoluto  alcohol,  two  of  chloroform,  and  three  of  etiier. 
This  is  less  disagreeable  than  ether,  and  has  not  the  over-relaxing 
effects  of  chloroform. 

IJearing  in  mind  the  tendency  of  chloroform  to  ])roduce  uterine 
relaxation,  more  than  ordinary  precautions  shoidd  always  be  taken 
against  post-j)artuni  hemorrhage  iu  all  cases  iu  whidi  it  has  been 
f  reely  ad  m  i  n  i  stered . 

In  cases  of  operative  midwifery  it  is  often  given  to  the  extent 
of  jn-oducing  complete  ana'sthesia.  In  all  such  cases  it  should  be 
administered,  when  possible,  by  another  medical  man,  and  not  by  the 
o[)erator,  because  the  giving  of  chloroform  to  the  surgical  degree  re- 
(piires  the  undivided  attention  of  the  administrator,  and  no  nian  can 
do  this  and  o})erate  at  the  same  time.  I  once  learnt  an  important  lesson 
on  this  point.  I  had  occasion  to  ai)ply  the  forceps  in  the  case  of  a  lady 
Avho  insisted  on  having  chloroform.  When  commencing  the  operation 
I  noticed  some  susi)icious  appearances  about  the  patient,  who  was  a 
large,  stout  woman  with  a  feeble  circulation.  I  therefore  sto})ped, 
allowed  her  to  regain  consciousness,  and  delivered  her  without  ana\s- 
thesia,  much  to  her  own  annoyance.  Just  one  month  after  labor  she 
Mcnt  to  a  dentist  to  have  a  tooth  extracted,  and  took  chloroform,  dur- 
ing the  inhalation  of  which  she  died.  This  im})ressed  on  my  mind  the 
lesson  that  no  man  can  do  two  things  at  tiie  same  time.  The  partial 
unconsciousness  of  incomplete  anaesthesia,  in  which  the  patient  is  rest- 
less and  tossing  about,  renders  the  a])j)lication  of  forceps  as  well  as  all 
other  operations  very  difficult.  Therefore,  unless  the  jiatient  can  be 
completely  and  fidly  anesthetized,  it  is  better  to  operate  without  chloro- 
form being  given  at  all. 

[In  the  United  States  the  dangers  attending  the  use  of  chloroform 
in  obstetric  practice  have,  in  large  measin-e,  banished  it  from  the  lying- 
in  chamber.  Some  obstetricians  in  our  chief  cities  still  resort  to  it  with 
little  hesitation,  believing  that  by  great  carefulness  in  its  administration, 
and  l)y  the  sul)stituti()n  of  ether  in  exccj>tional  cases,  all  danger  may  be 
avoided.  Otiiers  have  a  very  great  fear  of  it,  and  universally  trust  to 
the  safer  ana'stlietie.  It  is  an  error  to  su]>pose  that  the  ]iarturient  state 
robs  chloroform  of  much  of  its  danger,  the  a])])arent  innnunity  being 
due  to  its  intermittent  and  incomplete  administration  ;  complete  anaes- 
thesia being  but  a  fraction  less  dangerous  than  in  siu'gical  ojieratious 
upon  women  who  are  not  pregnant.  Dr.  Lusk,  already  quoted,  after  a 
large  experience  with  the  use  of  chloroform,  says:  ^' Pafioifs  in  /ahor 
(Jo  iiotenjoii  (Oil/  (thmlnfc  imtnuiiifj/  from  fJic  ])cr)ii('ious  ejf'cct'i  of  cJi/oro- 
form."^  It  is  nmch  to  be  regretted  that  tliis  more  ])leasant  anasthetic 
is  so  much  more  dangerous  than  ether  as  an  inhalant ;  but  in  considera- 
tion of  the  difference  of  risk,  that  of  tlieir  relative  effects  upon  the  nose 

['  Opus  C(7.] 


PELVIC  PRESENTATIONS.  303 

and  trac'liea  is  scarcely  to  be  considered.  Chloroform  acts  u|)on  the 
respiratory  centres  just  as  ether  does  ;  and  this  is  an  element  of  daii<:;<'r 
in  each,  hut  is  capable  of  being  counteracted  by  artificial  res])ii'atioM. 
Hut,  beyond  this,  chloroform  is  i\\v  more  dan^-erous,  in  acting-  upon  the 
motor  ti'anolia  of  the  heart  and  i)i'o(,lucino;  sudden  death.  Accordintr 
to  the  experiments  of  Yulpian  u[)on  animals,  uot  more  than  one  case 
of  cardiac  failure  in  forty  can  be  restored  by  artificial  res})iration.  He 
atKrms  that  there  is  danger  at  the  comraencemeDt,  during  the  course, 
and  at  the  close  of  chloroformization,  and  even  some  hours  or  days 
subsequent  to  it.  Nelatou  made  the  important  discovery  that  the 
cc^rebral  anaemia  produced  by  chloroform,  with  its  accompanying  death- 
like condition,  might  be  remedied  by  long  perseverance  in  artificial  i-es- 
piration  with  the  patient  turned  head  downward. 

Antiesthesia  in  labor  is  much  less  popular,  both  with  obstetricians  and 
patients  in  this  country,  than  it  was  soon  after  its  introduction.  Im- 
provements in  the  purity  of  sulphuric  ether  have  made  the  narcosis 
more  reliable,  but  the  general  effect  upon  j)atients  varies  very  decidedly, 
being  all  that  can  be  desired  in  some,  and  just  the  reverse  in  others. 
Some  of  the  undesirable  effects  I  have  witnessed  are  intoxication,  with 
cessation  of  labor,  hysterical  excitement,  nightmare,  and  post-partum 
inertia  and  hemorrhage.  I  have  also  witnessed  the  most  delightful 
results  from  ether  that  could  be  desired.  In  a  small,  delicate  multip- 
ara, whose  mother  died  of  phthisis,  and  to  whom  I  had  been  obliged 
to  administer  stimulants  in  the  first  and  much  of  the  second  stage  of 
labor,  the  use  of  ether  had  the  effect  to  revolutionize  her  condition. 
Her  pulse  became  strong ;  her  expulsive  power  increased ;  she  had  no 
suflFering ;  her  placenta  was  expelled  without  accompanying  blood ;  and 
there  was  no  subsequent  uterine  relaxation.  But  such  cases  are,  unfor- 
tunately, exceptional. — Ed,] 


CHAPTER  V. 

PELVIC   PRESENTATIONS. 

Under  the  head  of  pelvic  presentations  it  is  customary  to  include 
all  cases  in  which  any  part  of  the  lower  extremities  of  the  child  presents.  \ 
By  some  these  are  further  subdivided  into  breech,  footlinr/,  and  l-nce  ' 
presentations;  but,  although  it  is  of  consequence  to  be  able  to  recognize 
the  feet  and  the  knee  when  they  present,  so  far  as  the  mechanism  and 
management  of  delivery  are  concerned  the  cases  are  identical,  and  there- 
fore may  be  most  conveniently  considered  together. 

Frequency. — Presentations   comino-    under  this  head  are  far  from 


t 


^-* 


.']()4  LABOR. 

iiiR-oinmoii  :  those  in  wliicli   llic  hrcccli  alone  occupies  the  pelvi.s  are 
^x.-  met  with,  according-  to  (hurcliiJl,  once  in  52  lal)ors,  wliile  Ranishothani 
^    estimates  that   it   ])rescnts  more  f'reciuently — viz.  onc(!  in  liS.H   hilxtrs. 
<      Footliiiii'  presentations  occur  only  once  in  1*2  cases.     They  are  j)r(tl)al)ly 
often  the  mere  conversion  oforij^inal  hreech  presentations,  the  i'eet  hav- 
ing come  down  during  the  labor,  either  in  consequence  of  the  sudden 
escape  of  the  liquor  amnii,  v.hen  the  breech  was  still  freely  movable 
above  the  brim,  or  from  some  other  cause.     Knee  presentations  are 
extremely  rare,  as  may  be  readily  understood  if  it  be  borne  in  mind  that 
to  admit  them  the  thighs  nuist  be  extended,  hence  the  vertical  measure- 
ment of  the  child  must  be  givatly  increased,  and  therefore  it  could   not 
be  readily  accommodated  within  the  uterine  cavity  unless  of  unusually 
small  size.     As  a  matter  of  fact,  Mme.  LaChapelle  found  only  one  knee 
presentation  in  upward  of  3000  cases. 

The  causes  of  pelvic  presentations  are  not  known.  They  are  ])rob- 
ably  the  same  as  those  which  produce  other  varieties  of  malpresenta- 
tions,  cspecially(an  excess  of  liquor  amniiand  slight  pelvic  contraction  : 
and  it  is  not  unlikely  that  m  certain  women  thci'e  may  be(sonie  pecu- 
liaritv  in  the  shape  of  the  uterine  cavity  which  favors  their  production} 
*  It  would  be  difficult  otherwise  to  explain  such  a  case  as  that  mentioned 
by  Yelpeau  in  which   the  Ijreoch  presented  in  six  labors. 

Prognosis. — The  results  as  regards  the  mother  are  in  no  way  more 
unfavorable  than  in  vertex  presentations.  The  first  stage  of 'tlie  lalTor 
is  generallv  tediouss,  since  the  large  rounded  mass  of  the  breech  does  not 
adapt  ifseTf  so"well  as  the  head  to  the  lower  segment  of  the  uterus,  and 
dilatation  of  the  cervix  is  consequently  apt  to  be  retarded.  ^The  second 
stage  is,  however,  if  anything,  more  rapid  than  in  vertex  cases;  and 
even  when  it  is  protracted  the  soft  breech  does  not  produce  such  inju- 
rious pressure  on  the  maternal  structures  as  the  hard  and  unyielding 
head. 

The  result  is  very  different  as  regards  the  child.  Dubois  calculated 
that  1  out  of  11  children  was  stillborn.  Churchill  estimates  the  mor- 
tality as  much  higher — viz.  1  in  31-.  The  latter  certainly  indicates  a 
larger  number  of  stilll)irths  than  is  consistent  with  the  experience  of 
most  practitioners,  and  more  than  should  occur  if  the  cases  be  })roperly 
managed  ;(but  there  can  be  no  doubt  that  the  risk  to  the  child  is,  even 
under  the  most  favorable  circumstances,  very  great)  (Even  when  the 
child  is  not  lost  it  may  be  seriously  injured.)  Dr.  Ruge  has  tabulated 
a  series  of  29  cases  in  which  there  were  found  to  be  fractures  of  bt>nes 
or  other  injuries.' 

The  chief  source  of  danger  is  pressui'e  on  the  umbilical  cord  in 
the  interval  elapsing  between  the  birth  of  the  body  and  the  liead. 
At  this  time  the  cord  is  very  generally  compressed  between  the  head  of 
the  child  and  the  pelvic  walls,  so  that  circulation  in  its  vessels  is  arrested. 
Hence  the  aeration  of  the  foetal  blood  cannot  take  ]>lace,  and  jnilmonary 
respiration  not  having  been  yet  established,  the  child  dies  asphyxiated. 
There  are  other  conditions  present  which  tend,  although  in  a  jninor 
degree,  to  produce  the  same  result.  One  of  these  is  that  the  pbc-enta 
is  probably  often  separivted  by  the  uterine  contractions  when  the  bulk 
'  Bull.  (/en.  de  Therap.,  August,  1875. 


PELVIC  PRESENTATIONS.  305 

of  the  body  is  being  expelled,  as,  indeed,  takes  place  under  analogous 
circumstances  when  the  vertex  presents,  the  necessary  result  being 
the  arrest  of  placental  respiration.  Joulin  thinks  that  the  same  effect 
may  be  produced  by  the  compression  of  the  placenta  between  the  con- 
tracted uterus  and  the  hard  mass  of  the  foetal  skull.  Probably  all  these 
causes  combine  to  arrest  the  functions  of  the  placenta  ;  and  if  the  deliv- 
ery of  the  head,  and  consequently  the  establishment  of  pulmonary  res- 
piration, be  delayed,  the  death  of  the  child  is  almost  inevitable.  The 
corollary  is  that  the  danger  to  the  child  is  in  direct  proportion  to  the 
length  of  time  that  elapses  between  the  birth  of  the  body  and  that  of  the 
head. 

The  risk  to  the  child  is  greater  in  footling  than  in  breech  cases,' 
because  in  the  former  the  maternal  structures  are  less  perfectly  dilated 
in  consequence  of  the  small  size  of  the  feet  and  thighs,  and  therefore  the 
birth  of  the  head  is  more  apt  to  be  delayed. 

Diagnosis. — Inasmuch  as  the  long  axis  of  the  child  corresponds 
with  the  long  axis  of  the  uterus  in  pelvic  as  in  vertex  presentations, 
there  is  notlihig  iu  the  shape  of  tlie  uterus  to  arouse  suspicion  as  to  the 
character  of  the  case.  Still,  it  is  often  sufficiently  easy  to  recognize  a 
pelvic  presentation  by  abdominal  examination  if  we  have  occasion  to 
make  one.  The  facility  with  which  it  may  be  done  depends  a  good 
deal  on  the  individual  patient.  If  she  be  not  very  stout,  and  if  the 
abdominal  parietes  be  lax  and  non-resistant,  we  shall  generally  be  able 
to  feel  the  round  head  at  the  uj)per  part  of  the  uterus,  much  firmer  and 
more  defined  in  outline  than  the  breech.  (The  conclusion  will  be  for- 
tified if  we  hear  the  fcjetal  heayt  beating  on  a  level  with  or  above  the 
umbilicus.\  The  greater  resistance  on  one  side  of  the  abdomen  will  also 
enable  us  to  decide  with  tolerable  accuracy  to  which  side  the  back  of 
the  child  is  placed.  Information  thus  acquired  is,  at  the  best,  uncer- 
tain, and  we  can  never  be  quite  sure  of  the  existence  of  a  pelvic  pres- 
entation until  we  can  corroborate  the  diagnosis  by  vaginal  examina- 
tion. " 

[In  view  of  the  greater  risk  to  the  life  of  the  foetus  in  a  delivery 
by  the  breech  over  that  by  the  vertex,  it  is  advisable,  when  the  posi- 
tion is  determined  while  the  membranes  are  still  intact,  to  change  the 
presentation  from  pelvic  to  cephalic  by  external  bimanual  manipula-j 
tion. — Ed.] 

The  first  circumstance  to  excite  suspicion  on  examination  per  vaginam, 
even  when  the  os  is  undilated,  is  the  absence  of  the  hard  globular  mass 
felt  through  the  lower  segment  of  the  uterus,  so  characteristic  of  vertex 
presentations. ^  When  the  os  is  sufficiently  open  to  allow  the  membranes 
to  protrude,  although  the  presenting  part  is  too  high  up  to  be  within 
reach,  we  may  be  struck  witli  the  peculiar  shape  of  the  bag  of  mem- 
branes,  which,  instead  of  being  rounded,  projects  a  considerable  distance 
through  the  os,  like  the  finger  of  a  glove.  This  is  a  peculiarity  met 
with  in  all  mal presentations  alike,  and  is,  indeed,  much  less  distinct  in 
breech  than  in  footling  presentations,  because  in  the  former^  the  mem- 
branes are  more  stretched,  just  as  they  are  in  vertex  cases.  '^Vhen  the 
membranes  rupture,  instead  of  the  waters  dribbling  away  by  degrees^ 
they  often  escape  with  a  rush,  in  consequence  of  the  pelvic  extremity 

20 


306  LABOR. 

not  filling  up  the  lower  part  nC  the  iitorus  so  accurately  as  the  head, 
■which  acts  lus  a  sort  o-l'  i)all-\:iiv(-'  and  |)i-('vcnts  the  sudden  and  i-uinplete 
dischai'go  of  the  waters. 

Often  on  first  examining,  even  when  the  membranes  arc  ruptured, 
the  presentation  is  too  high  up  to  be  made  out  accurately.  All  that  we 
can  be  certain  of  is,  that  it  is  not  the  head  ;  and  the  case  nuist  be  csire- 
i'ully  watched  and  exaniinations  fri'(|uently  repeated  until  the  precise 
iKitiiiv  of  the  j)resentation  ean  be  established,  it'  the  breech  pi'esent, 
the  finger  first  impinges  on  a  round,  soft  })rominence,  on  depressing 
>viiieli  a  bony  protul)erance,  the  trochanter  major,  Ciui  be  felt.  (Jn 
})assing  the  finger  upward  it  reaches  a  groove,  beycmd  whi(;h  a  similar 
fleshy  mass,  the  other  buttock,  can  be  felt.  In  this  groove  various 
characteristic  j)oints  diagnostic  of  the  presentation  can  be  made  out. 
Toward  one  end  we  can  feel  the  movable  tij)  of"  the  coccyx,  and  above 
^  it  the  hard  .sgcrum  with  its  rough  project jng  ju'omiiienccs.  These  points, 
^  ^  if  accurately  Tnarte  out,  are  quite  cTiaracteristic,  and  resemble  nothing  in 
any  other  presentation.  In  front  there  is  the  anus,  in  which  it  is  some- 
times, but  by  no  means  ahvays,  possible  to  insert  the  tip  of  the  finger. 
If  this  can  be  done,  it  is  easy  to  distinguish  it  from  the  mouth,  with 
Avhicli  it  might  be  confounded,  by  observing  that  the  hard  alveolar 
ridges  are  not  contained  within  it.  Still  more  in  front  we  mav  find  the 
genital  organs,  the  scrotum  in  male  children  being  often  much  swollen 
if  the  labor  has  been  protracted.  Thus  it  is  often  possible  to  recognize 
the  sex  of  the  child  before  birth. 

The  l2i'eech  might  be  mistaken  for  the  face,  especially  if  the  latter  be 
much  swollen  ;  but  this  mistake  can  readily  be  avoidal  by  feeling  the 
spinous  processes  of  the  sacrum. 

Thejvuee  is  recognized  by  its  having  two  tuberosities  with  a  depres- 
sion between  them.  It  might  be  confounded  with  the  heel,  the  elbow, 
or  the  shoulder.  From  the  heel  it  is  distinguished  by  having  two 
tuberosities  instead  of  one ;  from  the  elbow,  by  the  latter  having  one 
sharp  tuberosity,  with  a  depression  on  one  side,  instead  of  a  central 
depression  and  two  lateral  ])rominences  ;  and  from  the  shoulder,  by  the 
latter  being  more  rounded,  having  only  one  prominence,  running  from 
which  the  acromion  and  clavicle  can  be  traced. 

t     The,  foot  may  be  mistaken  for  the  hand.     This  errc»r  will  be  avoided 

^VxMmy  remembering  that  all  the  toes  are  in  the  same  line,  and  that  the  great 

^     I     toe  cannot  be  brought  into  apjiosition  with  the  others,  as  the  thumb  can 

J^ftA|,»with  the  fingers.     The  internal  border  of  the  foot  is  nuich  tiiicker  than 

'  vM*  1    ^^^  external,  whereas  the  two  bordei^s  of  the  hand  are  of  the  same  thick- 

j    ness.     Moreover,  the  foot  is  articulated  at  right  angles  to  the  leg,  and 

I    cannot  be  brought  into  a  line  with  it,  as  the  hand  can  with  the  arm. 

Finally,  the  projection  of  the  calcaneum  is  characteristic  and  resembles 

nothing  in  the  hand. 

Mechanism. — As  is  the  case  in  other  presentations,  obstetricians 
have  very  variously  subdividcxl  breech  presentations  with  the  effect  of 
needlessly  com})licating  the  subject.  The  simplest  division,  and  that 
which  will  most  readily  imj^rcss  itself  on  the  memory  of  the  student,  is 
to  describe  the  breech  as  ])resenting  in  four  positions,  analogous  to  those 
of  the  vertex,  the  sacrum  being  taken  as  representing  the  occiput,  and 


PELVIC  PRESENTATIONS.  307 

the  positions  being  numbered  according  to  the  part  of  the  pelvis  to 
which  it  points.     Thus  we  liave — 

First,  or  left  sdcro-anterior  (sacro-lseva  anterior,  s.  L.  A.,  correspond- 
ing to  the  first  position  of  the  vertex).  The  sacrum  of  the  child  points 
to  the  left  foramen  ovale  of  tlie  mother. 

Second,  or  right  sacro-anterior  (sacro-dextra  anterior,  s.D.  A.,  corre- 
sponding to  the  second  vertex  position).  The  sacrum  of  the  child  points 
to  the  right  foramen  ovale  of  the  mother. 

Third,  or  right  sncro-posterior  (sacro-dextra  posterior,  S.D. P.,  cor- 
responding to  the  third  vertex  position).  The  sacrum  of  the  child 
points  to  the  right  sacro-iliac  synchondrosis  of  the  mother. 

Fourth,  or  left  sacro-posterior  (sacro-lseva  posterior,  S.  l.  p.,  corre- 
sponding to  the  fourth  vertex  position).  The  sacrum  of  the  child 
points  to  the  left  sacro-iliac  synchondrosis  of  the  mother. 
vOf  these,  as  with  the  corresponding  vertex  positions,  the  first 
(s. L. A.)  and  third  (s.D. r.)  are  the  most  common,^ their  comparative 
frequency  no  doubt  depending  on  the  same  causes.  The  mechanical 
conditions  to  which  the  presenting  part  is  subjected  are  also  identical, 
but  the  alterations  of  position  of  the  breech  in  its  progress  are  by  no 
means  so  uniform  as  those  of  the  head,  on  account  of  its  less  perfect 
adaptation  to  the  pelvic  cavity.  The  mechanism  of  the  delivery  of  the 
shoulders  and  head  in  breech  presentations,  moreover,  is  of  much 
greater  practical  importance  than  that  of  the  body  in  vertex  presen- 
tations, inasmuch  as  the  safety  of  the  child  depends  on  its  speedy  and 
satisfactory  accomplishment.  Bearing  these  facts  in  mind,  it  will 
suffice  to  describe  briefly  the  phenomena  of  delivery  in  the  first 
(s. L.A.)  and  third  (s.D. p.)  breech  positions. 

Position  of  the  Child  at  Brim. — In  the  first  position  (s. L.A.) 
(Fig.  Ill)  the  sacrum  of  the  child  points  to  the  left  foramen  ovale; 
its  back  is  consequently  placed  to  the  left  side  of  the  uterus  and 
anteriorly,  and  its  abdomen  looks  to  the  right  side  of  the  uterus  and 
])osteriorly.  The  sulcus  between  the  buttocks  lies  in  the  right  oblique 
diameter  of  the  pelvis,  while  the  transverse  diameter  of  the  buttocks 
lies  in  the  left  oblique  diameter,  the  left  buttock  being  most  easily 
within  reach.  As  in  vertex  presentations,  the  hips  of  the  child  lie  on 
the  same  level  at  the  pelvic  brim,  although  Naegele  describes  the  left 
hip  as  placed  lower  than  the  right. 

As  the  pains  act  on  the  body  of  the  child  the  breech  is  gradually 
forced  through  the  pelvic  cavity,  retaining  the  same  relations  as  at  the 
brim,  its  progress  being  generally  moi'e  slovv  than  that  of  the  head,      .-^ 
until  it  reaches  the  lower  pelvic  strait,  when  the  same  mechanism  which       \ 
produces  rotation  of  the  occiput  comes  to  operate  upon  it.     The  result  \^^ 
is  a  rotation  of  the  child's  pelvis,  so  thatiits  transverse  diameter  comes 
to  lie  approximately  in  the  antero-posterior  diameter  of  the  outlet)  'its 
antero-posterior  diameter  corresponds  to  the  transverse  diameter  oi  the 
mother's  pelvis,  the_left  liip  lies  behind  the  pubes  and  the  right  toward 
the  sacrum.     The  rotation,  which  is  admitted  by  the  majority  of  obstet- 
ricians, is  altogether  denied  by  Naegele.     There  can  be  no  doubt,  how- 
ever, that  it  does  generally  take  place,  but  by  no  means  so  constantly  as  the 
corresponding  rotation  of  the  vertex;  and/ it  is  not  uneonnnon  for  it  to 


308  LABOR. 


be  entirely  absent  and  for  the  hips  to  be  bom  in  the  oblique  diameter 
of  the  outletj)  (^The  body  ol"  the  chiltTTs  said  frequently  not  to  follow 


Fi(i.  111. 


First,  or  Left  Sacro-anterior  Position  (s.  l.  a.)  of  the  Breech. 

the  movement  imparted  to  the  hips,  so  that  there  is  more  or  less  of  a 
twist  iu  the  vertebral  column.^ 

The  left  hip  now  becomes  firmly  fixed  behind  the  pubes,  and  a  move- 

FiG.  112. 


Passage  of  the  Slioul.i.  r>  and  Partial  Rotation  of  the  Tliorax. 

ment  of  extension  analogous  to  that  of  the  head  in  vertex  presentations 
takes  place.  Tlic  right  or  posterior  hip  revolves  round  the  fixed  one, 
gradually  distends  (the  perippnm^  nnd  is  expelled  first,  the  left  hip 
rapidly  following.  (As  soon  as  both  hi]is  a're  born  tiie  feet  slip  out, 
unless  the  legs  are  completely  extended  upon  the  child's  abdomen.'N 
The  shoulders  soon  follow,  lying  in  the  left  oblique  diameter  of  the 
pelvis  (Fig.  112).     The  left  shoulder  rotates  forward  behind  the  pubes, 


PELVIC  PRESENTATIONS.  309 

where  it  becomes  fixed,  the  right  shoulder  swccpiug  over  the  perineum 
and  being  born  first.  The  arms  of  tlie  child  are  generally  found 
placed  upon  its  thorax,  and  are  born  before  the  shoulders.  Sometimes 
they  are  extended  over  the  child's  head,  thus  causing  considerable  delay 
and  greatly  increasing  the  risk  to  the  child.  (It  is  now  generally 
admitted  that  sucli  extension  is  most  apt  to  occur  when  traction  lias 
been  made  on  the  child's  body  with  the  view  of  hastening  delivery,  and 
that  it  is  rarely  met  with  when  the  expulsion  of  the  body  is  left  entirely 
to  the  normal  powers.  J 

Delivery  of  the  Head. — When  the  shoulders  are  expelled  the  head 
enters  the  pelvis  in  the  opposite,  or  right  oblique,  diameter,  the  face  look- 
ing to  the  right  sacro-iTiac^^nchondrosis.  As  the  greater  part  of  the 
child  is  now  expelled,  and  as  the  head  has  entered  the  vagina,  the  uterus, 
having  a  comparatively  small  mass  to  contract  upon,  must  obviously  act 
at  a  mechanical  disadvantage.  Still,  the  pressure  of  the  head  on  the 
vagina  is  a  powerful  inciter,  the  accessory  muscles  of  parturition  are 
brought  into  strong  action,  and  there  may  be  sufficient  force  to  ensure 
expulsion  of  the  head  without  artificial  aid.  On  account  of  the  great 
resistance  to  the  descent  of  the  occiput  from  its  articulation  with  the 
spinal  column,  the  pains  have  the  effect  of  forcing  down  the  anterior 
portion  of  the  head,  and  this  ensures  the  complete  flexion  of  the  chin 
upon  the  sternum  (Fig.  113).     This  is  a  great  advantage  from  a  mechan- 

FiG.  113. 


Descent  of  the  Head. 


ical  point  of  view,  as  it  causes  the  short  occipito-mental  diameter  of  the 
head  to  enter  the  pelvis  in  the  axis  of  the  uterus  and  the  brim.  If  the 
head  should  be  in  a  state  of  partial  extension — as  sometimes  happens 
when  the  pelvis  is  usually  roomy — the  occipito-frontal  diameter  is 
placed  in  a  similar  relation  to  the  brim — a  position  certainly  less  favor- 
able to  the  easy  birth  of  the  head.  As  the  head  descends  it  experiences 
a  movement  of  rotation,  the  occiput  passing  forward  and  to  the  right 
behind  the  pubic  arch,  the  flice  turning  backward  into  the  hollow  of  the 
sacrum.  The  body  of  the  child  will  be  observed  to  follow  this  move- 
ment, so  that  its  back  is  turned  toward  the  mother's  abdomen,  its 
anterior  surface  to  the  perineum.     The  nape  of  the  neck  now  becomes 


■■«MMMnda«Ma«MMaM 


310  LABOR. 

firmly  fixed  uikIci'  tlic  arcli  <»t'  the  ])iil)c>;  the  pains  act  chiefly  on  the 
anTeVior  portion  of  the  head  and  cause  it  to  sweej)  over  tlie  perineum, 
the  cliin  hcin*];  first  horn,  then  the  mouth  and  forehead,  and  lastly  the 
occiput. 

It  is  nei'dless  to  descril)e  the  differences  i)et\veen  the  mechanism  of 
the  second  (s.  d.  a.)  and  first  (s,  l.  a.)  positions,  which  the  student,  who 
lias  mastered  the  sui)jeet  of  vertex  presentations,  will  readily  uuder- 
staud.  It  is  necessary,  however,  to  say  a  few  words  as  to  sacro-poste- 
rior  positions,  choosing  for  that  purpose\jhe  third  (s.  D.  P.),  which  is  the 
more  common  of  the  twoj  This  is  exactly  the  opposite  of  the  first 
(s.  L.  A.)  position.  The  sacrum  of  the  child  ]»oints  to  the  ri<rht  sacro-iliac 
synchondrosis ;  its  abdomen  looks  forward  and  to  the  left  side  of  the 
mother.  The  transverse  diameter  of  the  child's  })elvis  lies  in  the  left 
oblique  diameter,  the  rij^ht  hip  being  anterior.  The  birth  of  the  body 
generally  takes  place  exactly  in  the  May  that  has  been  already  describee!, 
the  right  lup  being  toward  the  pidjcs, 

(AsiheTead  descends  into  tlie  pelvis  the  occi})ut  most  usually  rotates 
along  its  right  side — the  rotation  having  been  often  already  |)artially 
effected  when  that  of  the  hij)s  had  been  made — until  it  comes  to  rest 
behind  the  pubes,  the  face  passing  backward  along  the  left  side  of  the 
pelvis  into  the  hollow  of  the  sacrum.  This  change  corresponds  exactly 
to  the  anterior  rotation  of  the  occiput  in  occipito-posterior  positions,  and 
is  the  natural  and  favorable  termination. 

/  Sometimes  further  rotation  does  not  take  place,  and  the  occiput  then 
turns  backward  into  tlie  hollow  of  the  sacrum,'  A^'llat  then  generally 
occurs  is,  that  the  pains  continue,  for  the  I'eason  already  mentioned,  to 
depress  the  chin  and  produce  strong  flexion  of  the  face  on  the  sternum, 
the  occiput  becoming  fixed  on  the  anterior  border  of  the  ])eriiieum. 
IThe  pains  continue  to  act  chiefly  on  .the  anterior  })art  of  the  head,  the 
face  is  born  first  behind  the  pnl)es,  ^heocciput  only  slipping  over  the 
perineum  after  the  forehead  has  been  expelled. '^ 

The  second  mode  of  termination  of  such  positions  is  mentioned  in 
most  works  on  the  authority  of  one  or  two  recorded  cases,  but,  although 
mechanically  possible,  it  is  certainly  an  evii'nt  of  extreme  rarity.  (The 
chin,  instead  of  being  flexed  on  the  sternum,  is  greatly  extended,  so  that 
the  face  of  the  child  looks  upward  toward  the  ju'l vie  brim. ^  The  child 
then  hitches  over  the  uj)per  edge  of  the  pubes,  and  becomes  fixed  there, 
while  the  force  of  the  uterine  contractions  is  expended  on  the  posterior 
part  of  the  head,  which  descends  through  the  ])elvis,  distending  the 
perineum,  and  is  born  first,  the  face  snl)sequently  following. 

The  mechanism  of  the  deliveryTiFlhe  liody  and  head  in  cases  in 
which  the  feet  originally  present  does  not  difler,  in  any  important 
respect,  from  that  which  has  been  already  described,  and  requires  no 
separate  notice. 

Treatment. — From  what  has  been  said  of  the  natural  mechanism,  it 
is  evident  that  one  of  the  most  fruitful  causes  of  difficulty  and  compli- 
cation is  undue  interference  on  the  part  of  the  j>ractitiouer.  It  is  no 
doubt  tempting  to  use  traction  on  the  partially-born  trunk  in  the  hope 
of  expediting  delivery  ;  but  when  it  is  remembered  that  this  is  almost 
certain  to  produce  extension  of  the  arms  above  the  he;ul,  and  subse- 


PELVIC  PRESENTATIONS.  311 

quently  extension  of  the  occiput  on  the  sj)ine,  both  of  which  seriously 
increase  the  difhculty  of  delivery,  the  necessity  of  leaving  the  case  as 
nuicli  as  possible  to  nature  will  be  apparent. 

Having  once,  therefore,  determined  the  existence  of  a  pelvic  presen- 
tation, nothing  more  should  be  done  until  the  birth  of  the  breech.  The 
inembranes  sliould  be  even  more  carefully  prevented  from  prematurely 
r^pturmg  tluin  in  vertex  ] )resentations.  since  thev  serve  to  dilate  the 
genitid  j)a.ssages  better  than  the  presenting  part.  I  Ilence  they  should 
be  preserved  intact,  if  possible,  until  they  reach  the  floor  of  the  pel-' 
vis,  instead  of  being  punctured  as  soon  as  the  os  is  fully  dilated.  The 
breech  when  born  should  be  received  and  supported  in  the  palm  of, 
the  hand.) 

When  tlie  body  is  expelled  as  far  as  the  umbilicus,  the  dangers 
to  the  child  commence  ;  for  now  the  cord  is  apt  to  be  pressed  betweea 
the  body  of  the  child  and  the  pelvic  walls.  To  obviate  this  risk  as 
much  as  possible^  a  loop  of  the  cord  should  bp  pnllpd  down)  and 
carried  to  that  part  ot'  the  pelvis  where  there  is  most  room,  which, 
will  generally  be  opposite  one  or  tlie  other  sacro-iliac  synchondrosis 
As  long  as  the  cord  is  freely  pulsating  we  may  be  satisfied  that  the 
life  of  the  child  is  not  gravely  imperilled,  although  delay  is  fraught 
with  danger  from  other  sources  which  have  been  already  indicated 
In  most  cases  the  arras  now  slip  out ;  but  it  may  happen,  even  with 
out  any  fault  on  the  part  of  the  accoucheur,  that  they  are  extended 
above  the  head,  and  it  is  of  great  importance  that  we  should  be 
thoroughly  acquainted  with  the  best  means  of  liberating  them  from 
their  abnormal  position. 
''  They  must,  of  course,  never  be  drawn  directly  downward)  or  the 
almost  certain  result  would  be  fracture  of  the  fragile  bones.  \We 
should  endeavor  to  make  the  arm  sweep  over  the  fiice  and  chest  of 
the  child,  so  that  the  natural  movements  of  its  joints  should  not  be 
opposed.  If  the  shoulders  be  within  easy  reach,  the  finger  of  the 
accoucheur  should  be  slipped  over  that  which  is  posterior — because 
there  is  likely  to  be  more  space  for  this  manoeuvre  toward  the  sacrum 
— and  gently  carried  downward  toward  the  elbow,  wliich  is  drawn 
over  the  face,  and  then  onward,  so  as  to  liberate  the  forearm.  The 
same  manoeuvre  should  then  be  applied  to  the  opposite  arm.  It  may  be 
that  the  shoulders  are  not  easily  reached,  and  then  they  may  be 
depressed  by  altering  the  position  of  the  child's  body.  If  this  be 
carried  well  up  to  the  mother's  abdomen,  the  posterior  shoulder  Avill 
be  brought  lower  down  ;  and  by  reversing  this  procedure  and  carry- 
ing the  body  back  over  the  perineum  the  anterior  shoulder  may  be 
similarly  depressed.  It  is  only  very  exceptionally,  however,  that 
these  expedients  are  required. 

Birth  of  the  Head. — The  arms  being  extracted,  some  degree  of 
artificial  assistance  is  at  this  time  almost  always  required.  If  there 
be~niuch  delay,  the  child  will  almost  certainly  perish.  Attempts  have 
been  made,  in  cases  in  which  delivery  of  the  head  could  not  be  rap- 
idly eifected,  to  estal)lisli  pulmonary  respiration  by  passing  one  or  two 
fingers  into  the  vagina,  so  as  to  press  it  back  and  admit  air  to  the 
child's   mouth,  or   by  passing   a   catheter   or   tube   into   the   mouth. 


t     y, 


312  LABOR. 

^'^oitliei*  of  tliose  expedients  is  reliai)le,  and  we  shctiiid  inilier  seek  to 
aid  imtiire  in  completing  the  l)iith  of"  tlie  liead  jls  ra])idiy  a.s  possi- 
ble. /^The  fii*st  thing  to  do,  supposing  the  face  to  have  rotated  into 
the  Aiivity  of  the  sacrum,  is  to  carry  the  body  of  the  child  well  up 
toward  the  pubcs  and  abdomen  of  the  mother  without  ap})lving  anv 
traction,  for  fear  of  intcrteriiig  with  the  all-important  flexion  of  the 
I'hin  on  the  sternum.)  Jf  now  the  patient  bear  down  strongly,  the 
natural  powei-s  may  be  sufficient  to  complete  delivery.  If  tiiere  Ije 
any  delay,  traction  must  be  resorted  to,  and  we  mu.st  endeavor  to 
apply  it  in  such  way  as  to  ensure  flexion.  ^For  this  ])ur])ose,  while 
the  body  of  the  child  is  grasj)ed  by  the  left  hand  and  drawn  upwai-d 
toward  the  mother's  abdomen,  the  index  and  middle  fingers  of  the 
right  hand  are  placed  on  the  back  of  the  child's  neck,  so  that  their 
tips  press  on  either  side  of  the  base  of  the  occiput  and  pu.-jb-the  head 
into  a  state  of  flexion.  In  most  works  we  are  advised  to  pass  the 
inlJex"  and  middle  fingers  of  the  left  hand  at  the  same  time  over  the 
child's  face,  so  as  to  depress  the  superior  maxilla.  Dr.  Barnes  insists 
that  this  is  quite  unnecessary,  and  that  extraction  in  the  manner 
indicated,  by  pressure  on  the  occiput,  is  quite  sufficient.  Should  it 
not  prove  so,  flexion  of  the  chin  may  be  very  effectually  assisted  by 
downward  pressure  on  the  forehead  through  the  rectum.  One  or  two 
fingers  of  the  left  hand  can  readily  be  inserted  into  the  bowel,  and  the 
expulsion  of  the  head  is  thus  materially  facilitated. 

By  far  the  most  powerful  aid,  however,  in  hastening  delivery  of  the 
head,  shcjuld  delay  occur,  is  pj^;ssure  from  above.  This  has  been, 
strangely  enough,  almost  altogether  omitted  by  wflfers  on  the  subject. 
It  has  been  strongly  recommended  by  Professor  Penrose,  and  there 
can  be  no  question  of  its  utility.  Indeed,  as  the  uterus  contracts  tight- 
ly round  the  head  uterine  expression  can  be  applied  aluKJst  directly 
to  the  head  itself,  and  without  any  fear  of  deranging  its  projier  relation 
to  the  maternal  passages.  It  is  very  seldom  indeed  that  a  judicious 
combination  of  traction  on  the  part  of  the  accoucheur,  with  firm  pres- 
sure through  the  abdomen  a})plied  by  an  assistant,  will  fail  in  affecting 
delivery  of  the  head  before  the  delay  has  had  time  to  prove  injiwious 
to  the  child. 

Application  of  the  Forceps  to  the  After-coming  Head. — Many 
accoucheurs — anmng  others,  !Meigs  and  Kigby — advocate  the  ajiplica- 
tion  of  the  forceps  when  there  is  delay  in  the  birth  of  the  after-coming 
head.  If  the  delay  be  due  to  want  of  expulsive  force  in  a  pelvis  of 
normal  size,  manual  extraction  in  the  manner  just  described  will  be 
found  to  })e  sufficient  in  almost  every  case,  and  preferable,  as  being 
more  rapid,  easier  of  execution,  and  safer  to  the  child.  The  forceps 
may  be  quite  properly  tried  if  other  means  have  failed,  esj)ccially  if 
there  be  some  disprojxjrtion  between  the  size  of  the  head  and  the 
pelvis. 

Difficulties  in  delivery  may  also  occur  in  sacro-posterior  positions. 
Up  to  the  time  of  the  birth  of  the  head  the  labor  usually  ))rogresses 
as  readily  as  in  sacro-anterior  positions.  If  the  forward  rotation  of 
the  hips  do  not  take  place,  much  subsequent  difficulty  may  be  j)re- 
vented  by  gently  favoring  it  by  traction  apjilied  to  the  breech  during 


PELVIC  PRESENTATIONS.  313 

the  pains,  the  finger  Ijeing  passed  for  this  pui-poso  into  the  fold  of  the 
groin. 

It  is  after  the  birth  of  the  shonlders  that  the  absence  of  rotation  is 
most  likely  to  prove  troublesome.  It  has  been  recommended  that  the 
body  should  then  be  grasped  in  the  interval  between  the  pains  and 
twisted  round  so  as  to  bring  the  occiijut  forward.  It  is  by  no  means 
certain,  however,  that  the  head  Wduld  follow  the  movement  imparted 
to  the  body,  and  there  must  be  a  serious  danger  of  giving  a  fatal  twist 
of  the  neck  by  such  a  manoeuvre.  The  better  plan  is  to  direct  the  face 
backward  toward  the  cavity  of  the  sacrum,  by  pressing  on  the  anterior 
temple  during  the  continuance  of  a  pain.  In  this  Avay  the  proper  rota- 
tion will  generally  be  eifected  without  much  difficulty,  and  the  case  will 
terminate  in  the  usual  way. 

If  rotation  of  the  occiput  forward  do  not  occur,  it  is  necessary  for 
the  practitioner  to  bear  in  mind  the  natural  mechanism  of  delivery 
under  such  circumstances.  In  the  majority  of  cases  the  projDcr  plan  is 
to  favor  flexion  of  i\\Q  chin  by  upward  pressure  on  the  occiput,  and  to 
exert  traction  directly  backward,  remembering  that  the  nape  of  the  neck 
should  be  fixed  against  the  anterior  margin  of  the  perineum.  If  this 
be  not  remembered,  and  traction  be  made  in  the  axis  of  the  pelvic  out- 
let, the  delivery  of  the  head  will  be  seriously  impeded.  In  the  rare 
cases  in  which  the  head  becomes  extended  and  the  chin  hitches  on  the 
upper  margin  of  the  pubes,  traction  directly  forward  and  upward  may 
be  required  to  deliver  the  head ;  but  before  resorting  to  it  care  should 
be  taken  to  ascertain  that  backward  extension  of  the  head  has  really 
taken   place. 

It  remains  for  us  to  consider  the  measures  which  may  be  adopted  in 
those  troublesome  cases  in  which  the  breech  refuses  to  descend,  and 
becomes  impacted  in  the  pelvic  cavity  either  from  uterine  inertia  or 
from  disproportion  between  the  breech  and  the  pelvis.  The  peculiar 
shape  of  the  presenting  part  unfortunately  renders  such  cases  very 
difficult  to  manage. 

Three  measures  have  been  chiefly  employed :  1st,  the  forceps;  2d, 
bringing  down  one  or  both  feet,  so  as  to  break  up  the  presenting  part 
and  convert  it  into  a  footling  case ;  3d,  traction  on  the  breech,  either 
by  the  fingers,  a  blunt  hook,  or  fillet  passed  over  the  groin. 

Forceps. — The  forceps  has  generally  been  considered  unsuited  for 
breech  cases  in  consequence  of  its  construction  to  fit  the  fcetal  head, 
which  renders  it  liable  to  slip  when^applied  to  the  breech.  This  objec- 
tion, probably  to  a  great  extent  true  with  reference  to  most  forceps, 
seems  not  to  hold  good  when  the  axis-traction  forceps  of  Tarnier  or 
Simpson  is  used.  Lusk  strongly  recommends  it,  and  Harvey  of  Cal- 
cutta has  published  six  consecutive  cases  in  which  he  employed  this 
method  of  delivery — in  three  with  complete  success.  Truzzi,^  who 
has  written  strongly  in  favor  of  the  forceps  in  difficult  breech  cases, 
prefers  it  greatly  to  traction  either  by  the  fingers  or  the  fillet  when  the 
breech  is  high  in  the  pelvis,  and  recommends  that  in  order  to  secure  a 
strong  hold  the  blades  should  be  passed  so  that  their  extremities  extend 
above  the  crests  of  the  foetal  ilia,     I  have  only  used  it  myself  in  one 

1  Gaz.  Med.  Ital.  Lomb.,  August,  1SS3. 


314  LABOR. 

or  two  cases,  but  in  these  tlie  results  were  extremely  good,  anil  <lelivery 
\vi\s  effected  \\\\\\  a  facility  which  surprised  me;  and  I  can  see  ikj  objec- 
tion to  a  cautious  trial  <»f  the  instrument.  [A  betti  r-littin}x  instrument 
is  the  special  breech-forceps,  with  oval  feuestne,  Hat-ed<^ed  bhides,  and 
long  superimposed  shaidvs,  miKlelled  to  fit  the  sides  of  the  breech  over 
the  tntchanters  and  ilite. — Ed.] 

Bringing  Down  a  Foot. — liarnes  insists  on  the  superiority  of  the 
second  plan;  and(  there  can  be  no  ([uestion  that  if  a  foot  can  be  ^<>t 
down  the  accoucheur  has  a  com])lete  control  over  the  progress  of  the 
labor  wlucli  lie  can  gam  ui  no  other  way^  If  the  breech  be  arrested 
at  or  near  the  brim,  there  Mill  generally  be  no  great  difficulty  in  effect- 
ing the  desired  object,  (it  will  be  necessary  to  give  chloroform  to  the 
extent  of  complete  anaesthesia,) and  to  pass  the  hand  over  the  child's 
abdomen  in  the  same  manner  and  with  the  same  i)recautions  iis  in  per- 
forming podalic  version  until  a  foot  is  reached,  which  is  seized  and 
pulled  down.  If  the  ^eet  be  placed  in  the  usual  May  close  to  the  but- 
tocks, no  great  difficulty  is  likely  to  be  expericnced.j  (  If,  however,  the 
legs  be  extended  on  the  abdomen,  it  Avill  be  necessary  to  introduce  the 
hand  and  arm  very  deeply,  even  up  to  the  fundus  of  the  uterus — a 
procedure  which  is  always  difBcult  and  which  may  be  very  hazardous. 
Nor  do  I  think  that  the  attempt  to  bring  down  the  feet  can  be  safe 
when  the  breech  is  low^  down  and  fixed  in  the  pelvic  cavity.  A  cer- 
tain amount  of  repression  of  the  breech  is  possible,  but  it  is  evident 
that  this  cannot  be  safely  attempted  when  the  breech  is  at  all  low 
doMU. 

Traction  on  the  Groin. — Under  such  circumstances  traction  is  our 
only  resource,  and  this  is  always  difficult  and  often  unsatisfactory.  Of 
all  contrivances  for  this  purpose,  none  is  better  than  the  hand  of  the 
accoucheur.  The  index  finger  can  generally  be  slipped  over  the  groin 
M'ithout  difficulty,  and  traction  can  be  api)lied  during  the  pains.  Fail- 
ing this  or  when  it  proves  insufficient,  an  attempt  should  be  made  to 
pass  a  fillet  over  the  groins.  A  soft  silk  handkerchief  or  a  skein  of 
worsted  answers  best,  l)ut  is  by  no  means  easy  to  aj)ply.  The  simplest 
plan,  and  one  which  is  far  better  than  the  expensive  instruments  con- 
trived for  the  purpose,  is  to  take  a  stout  piece  of  co])per  wire  and  bend 
it  double  into  the  form  of  a  hook.  The  extremity  of  this  can  gener- 
ally l)e  guided  over  the  hips,  and  through  its  loo})ed  end  the  fillet  is 
passed.  The  wire  is  now  withdrawn,  and  carries  the  fillet  over  the 
groins.  I  have  found  this  simple  contrivance,  Mhich  can  be  manu- 
factured in  a  few  moments,  very  useful,  and  by  means  of  such  a  fillet 
very  considerable  tractive  force  can  be  employed.  The  use  of  a  soft 
fillet  is  in  every  way  preferable  to  the  blunt  hook  which  is  contained 
in  most  obstetric  bags.  A  hard  instrument  of  this  kind  is  <|uite  as 
difficult  to  apply,  and  any  strong  traction  employed  by  it  is  almost 
certain  to  seriously  injure  the  delicate  fcotal  structures  over  whi<'h  it  is 
placed.  As  an  auxiliary  the  emj)loyment  of  uterine  expression  should 
not  be  forgotten,  since  it  may  give  material  aid  Avhen  tlie  difficulty  is  only 
due  to  uterine  inertia.  After  a  difficult  breech  labor  is  completed  the 
child  should  be  carefully  examined  to  see  that  the  bones  of  the  thighs 
and  arms  have  not  been  injured.     Fractures  of  the  thigh  are  far  from 


PRESENTATIONS  OF  THE  FACE.  315 

uncommou  in  such  cases,  and  tlie  soft  bones  of  the  newly-ljorn  child 
will  readily  and  ra])idly  unite  if  placed  at  once  in  proper  splints. 

Embryotomy. — Failing  all  endeavors  to  deliver  by  these  expedients, 
there  is  no  resource  left  but  to  break  up  the  presenting  part  by  scissors 
or  by  craniotomy  instruments ;  but,  fortunately,  so  extreme  a  measure 
is  but  rarely  necessary. 


CHAPTER  VI. 

PEESENTATIONS  OF  THE   FACE. 

Presentations  of  the  face  are  by  no  means  rare,  and,  although  in 
the  great  majority  of  cases  they  terminate  satisfactorily  by  the  unassisted 
powers  of  nature,  yet  every  now  and  again  they  give  rise  to  much  dif- 
ficulty, and  then  they  may  be  justly  said  to  be  amongst  the  most  formi- 
dable of  obstetric  complications.  It  is  therefore  essential  that  the  prac- 
titioner should  thoroughly  understand  the  natural  history  of  this  variety 
of  presentation,  with  tlie  view  of  enabling  him  to  intervene  with  the  best 
prospect  of  success. 

The  older  accoucheurs  had  very  erroneous  views  as  to  the  mechanism 
and  treatment  of  these  cases,  most  of  them  believing  that  delivery  was 
impossible  by  the  natural  efforts,  and  that  it  was  necessary  to  intervene 
by  version  in  order  to  effect  delivery.  Smellie  recognized  the  fact  that 
spontaneous  delivery  is  possible,  and  that  the  chin  turns  forward  and 
under  the  pubes ;  but  it  was  not  until  long  after  his  time,  and  chiefly 
after  the  appearance  of  Mme.  La  Chapelle's  essay  on  the  subject,  that 
the  fact  that  most  cases  could  be  naturally  delivered  was  fully  admitted 
and  acted  upon. 

Frequency. — The  frequency  of  face  presentation  varies  curiously  in 
different  countries.  Thus,  Collins  found  that  in  the  Rotunda  Hospital 
there  was  only  1  case  in  497  labors,  although  Churchill  gives  1  in  249 
as  the  average  frequency  in  British  j)ractice.  while  in  Germany  this  pres- 
entation is  met  with  once  in  169  labors.  '  The  only  reasonable  expla- 
nation of  this  remarkable  difference  is  that  the  dorsal  decubitus,  gener- 
ally followed  abroad,  favors  the  transformation  of  vertex  presentations 
into  those  of  the  face./ 

The  mode  in  which  this  change  is  effected — for  it  can  hardly  be  / 
doubted  that  in  the  large  majority  of  cases  face  presentation  is  due  to  a   ■ 
backward  displacement  of  the   occiput  after  labor  has  actually  com- 
menced, but  before  the  head  has  engaged  in  the  brim — has  been  made 
the  subject  of  various  explanations. 

It  has  generally  been  supposed  that  the  change  is  induced  by  a  hitch- 


31 G  LABOR. 

ing  of  the  occii)ut  on  the  l)riiii  of  tli<-  ixlvis,  so  its  to  produce  exteusiou 
of  the  head  ami  descent  of  tiie  face,  the  occurreuee  being  favored  by  the 
oblique  position  of  the  uterus  so  fre(juently  met  \vitli   in  pregnancy, 


Hecker'  attaches  considerable  importance  to  a  peculiarity  inlthe  shape 
of  the  fu'tal  head]  generally  observed  in  face  presentations,  thV  cranium 
having  the  dolicKoccphalons  form,  })romincnt  posteriorly  with  the  occi- 
put projecting,  which  has  the  effect  of  incrcasijig  the  length  of  the  pos- 
terior cranial  lever  arm  and  facilitating  extension  when  cii'cumstanees 
favoring  it  are  in  action.  Dr.  Duncan^  thinks(that  uterine  obliquity 
has  much  influence  in  the  })roduction  of  face  ])resentation,  but  in  a  dif- 
ferent way  to  that  al)ovc  referred  to)  He  points  (jut  that  when  obli<juity 
is  very  marked  a  curve  in  the  geniial  passages  is  produced,  the  convex- 
ity of  which  is  directed  to  the  side  toward  which  the  uterus  is  deflected. 
AMien  uterine  contraction  commences  the  fcetus  is  propelled  downward, 
and  the  part  corresponding  to  the  concavity  of  the  curve  is  acted  on  to 
the  greatest  advantage  by  the  propelling  force,  and  tends  to  descend. 
Should  the  occiput  happen  to  lie  in  the  convexity  of  the  curve  so 
formed,  the  tendency  will  be  for  the  forehead  to  descend.  In  the 
majority  of  cases  its  descent  will  be  prevented  Ity  the  increased  resistance 
it  meets  w^ith  in  consequence  of  the  greater  length  of  the  anterior  cra- 
nial lever  arm ;  but  if  the  uterine  obliquity  be  extreme  this  may  be 
counterbalanced,  and  a  face  presentation  ensues.  The  influence  of  this 
obliquity  is  corroborated  by  the  observation  of  Baudeloccpie,  that  the 
occiput  in  face  presentations  almost  invariably  corresponds  to  the  side  of 
the  uterine  obliquity.  A  further  corroboration  is  afforded  by  the  fact 
that  in  face  presentation  the  occiput  is  much  more  frequently  directed  to 
the  right  than  to  the  left,  while  right  lateral  obliquity  of  the  uterus  is 
also  much  more  connnon. 

These  theories  assume  that  face  presentations  are  produced  during 
labor.  In  a  few  cases  they  certainly  exist  before  labor  has  commenced. 
It  is  possible,  however,  as  we  know  that  uterine  contractions  exist  inde- 
pendently of  actual  labor,  that  similar  causes  may  also  be  in  operation, 
although  less  distinctly,  before  the  commencement  of  labor. 

The  diagnosis  is  often  a  matter  of  considerable  difficulty  at  an  early 
period  of  labor,  before  the  os  is  fully  dilated  and  the  membranes  rup- 
tured, and  when  the  face  has  not  entered  the  pelvic  cavity.  (The  finger 
then  impinges  on  the  rounded  mass  of  tlie  forehead,  which  may  very 
readily  be  mistaken  for  the  vertex.  At  this  stage  the  diagnosis  may  be 
facilitated  by  abdominal  palpation  in  the  way  suggested  by  Hecker.  (  If 
the  face  is  presenting  at  the  brim,  pal])ation  will  enable  us  to  distinguish 
a  hard,  firm,  and  rounded  body  immediately  above  the  pubes,  which  is 
the  forehead  and  sinciput  ;  on  the  other  side  will  be  felt  an  indistinct, 
soft  substance,  corres]ionding  to  the  thorax  and  neck.  \  When  labor  is 
advanced  and  the  head  has  somewhat  descended,  or  when  the  membranes 
are  ruptured,  we  should  be  able  to  make  out  the  nature  of  the  presenta- 
tion with  certainty.  (The  diagnostic  marks  to  be  relied  on  are  the  edges 
of  the  orbits,  the  prominence  of  the  nose,  the  nc^rils  (their  oriflces  show-, 
ing  to  which  part  of  the  pelvis  the  chin  is  turned),  and  the  aivity  of  the 
niouth  with  the  alveolar  ridges.  \  If  these  be  made  out  Siitisfactorily,  no 


gen 


*  Ueber  die  Schddel/oitn  bei  Gesichtdagen.  '  Edin.  Med.  Jovrn.,  vol.  xv. 


PRESENTATIONS  OF  THE  FA  CI-:.  317 

mistake  should  occur. (^Tlie  most  difficult  cases  are  those  in  which  the 
face  has  been  a  considerable  time  in  the  pelvis.  Under  such  circum- 
stances the  cheeks  become  greatly  swollen  and  pressed  together,  so  as  to 
resemble  the  nates.*  The  nose  might  then  be  mistaken  for  the  genital 
organs,  and  the  mouth  for  the  anus.  The  orbits,  however,  and  the  alve- 
olar ridges  reseml)Ie  nothing  in  the  breech,  and  should  be  sufficient  to 
])reveut  error.  Considerable  care  should  be  taken  not  to  examine  too 
frequently  and  roughly,  otherwise  serious  injury  to  the  delicate  struc- 
tures of  the  face  might  be  inflicted.  When  once  the  presentation  has 
been  satisfactorily  diagnosed,  examinations  should  be  made  as  seldom 
as  possible,  and  only  to  assure  ourselves  that  the  case  is  progressing 
satisfactorily. 

Mechanism. — If  we  regard  face  presentations,  as  we  are  fully  justi- 
fied in  doing,  as  being  generally  produced  by  the  extension  of  the  occi- 
put in  what  M^ere  originally  vertex  ])resentations,  we  can  readily  under- 
stand that  the  position  of  the  face  in  relation  to  the  pelvis  must 
correspond  to  that  of  the  vertex.  This  is,  in  fact,  what  is  found  to  be 
the  case,  the  forehead  occupying  the  position  in  which  the  occiput  would 
have  been  placed  had  extension  not  occurred. 

The  face,  then,  like  the  head,  may  be  placed  with  its  long  diameter 
corresponding  to  almost  any  of  the  diameters  of  the  brim,  but  most 
generally  it  lies  either  in  the  transverse  diameter  or  between  this  and  the 
oblique,  while  as  it  descends  in  the  pelvis  it  more  generally  occupies  one 
or  other  of  the  oblique  diameters.  It  is  common  in  obstetric  works  to 
describe  two  principal  varieties  of  face  presentation — viz.  the  right  and 
left  mento-iliac,  according  as  the  chin  is  turned  to  one  or  other  side  of 
the  pelvis.  It  is  better,  however,  to  classify  the  positions  in  accordance 
with  the  part  of  the  pelvis  to  which  the  chin  points.  AVe  may  there- 
fore describe  four  positions  of  the  face,  each  being  analogous  to  one  of 
the  ordinary  vertex  presentations,  of  which  it  is  the  transformation. 

The  Four  Positions  generally  Met  -with, — First  position  (mento- 
dextra  posterior,  m.  d.  p.). — The  chin  points  to  the  right  sacro-iliac  syn- 
chondrosis, the  forehead  to  the  left  foramen  ovale,  and  the  long  diam- 
eter of  the  face  lies  in  the  right  oblique  diameter  of  the  pelvis.  This 
corresponds  to  the  first  position  of  the  vertex,  and,  as  in  that,  the  back 
of  the  child  lies  to  the  left  side  of  the  mother. 

Second  position  (mento-laeva  posterior,  m.  l.  p.). — The  chin  points  to 
the  left  sacro-iliac  synchondrosis,  the  forehead  to  the  right  foramen 
ovale,  and  the  long  diameter  of  the  face  lies  in  the  left  oblique  diameter 
of  the  pelvis.     This  is  the  conversion  of  the  second  vertex  position. 

Third  position  (mento-lajva  anterior,  M.  L.  A.). — The  forehead  (Fig. 
114)  points  to  the  right  sacro-iliac  synchondrosis,  the  chin  to  the  left 
foramen  ovale,  and  the  long  diameter  of  the  face  lies  in  the  right 
oblique  diameter  of  the  pelvis.  This  is  the  conversion  of  the  third  ver- 
tex position. 

Fourth  position  (mento-dextra  anterior,  m.  d.  a.). — The  forehead 
points  to  the  left  sacro-iliac  synchondrosis,  the  chin  to  the  right  foramen 
ovale,  and  the  long  diameter  of  the  face  lies  in  the  left  oblique  diam- 
eter of  the  pelvis.     This  is  the  conversion  of  the  fourth  vertex  position. 

The  relative  frequency  of  these  presentations  is  not  yet  positively 


318  LABOR. 


ascertained.'  It  is  ctrtaiii  that  there  is  not  the  prepondemnce  of  fii-st 
facial  (m.  I).  P.)  tliat  there  is  of  first  vertex  (s.  i..  a.)  positicjns ; yancl  this 
may,  no  donbt,  be  exphiined  by  the  snpposition  that  an  unusual  vertex 
position  may  of  itself  lacilitate  the  transformation  into  a  face  preseuta- 


FiG.  114. 


Third  Position  (m.  l.  a  )  in  Face  Presentations. 

tion.  Winckel  concludes  that,  cceteris  paribus,  a  face  presentation  is 
more  readily  produced  when  the  back  of  the  child  lies  to  the  right  than 
Mheu  it  lies  to  the  left  side  of  the  mother;  the  reason  for  this  being 
probably  the  frequency  of  right  lateral  obliquity  of  the  uterus,  "\\'e 
shall  presently  see  that  with  very  rare  exceptions  it  is  absolutely  essen- 
tial that  the  chin  should  rotate  forward  under  the  pubes  before  delivery 
can  be  accomplished  ;  and  therefore  we  may  regard  the  third  and  fourtli 
face  positions,  in  which  the  chin  from  the  first  points  anteriorly,  as  more 
favorable  than  the  first  and  second. 

The  mechanism  of  delivery  in  face  is  practically  the  same  as  in  ver- 
tex presentations;  and  we  shall  have  no  difficulty  in  uudei'standing  it 
if  we  bear  in  mind  that  in  face  cases  the  forehead  takes  the  place  of,  and 
represents  the  occiput  in,  vertex  presentations.  For  the  purpo-se  of 
description  we  will  take  the  first  position  of  the  face. 

1.  The  first  step  consists  in  the  extension  of  the  head,  which  is 
effected  by  the  uterine  contractions  as  soon  as~the  mend)ranes  are  rup- 
tured. By  this  the  occiput  is  still  more  completely  pressed  back  on  the 
nape  of  the  neck,  and  the  fronto-mental,  rather  than  the  mento-breg- 
matic,  diameter  is  placed  in  relation  to  the  pelvic  brim.  This  corre- 
sponds to  the  stage  of  flexion  in  vertex  presentations. 

The  chin  descends  below  the  forehead  from  precisely  the  same  cause 
as  the  occiput  in  vertex  presentations.  On  account  of  the  extended 
position  of  the  head  the  presenting  face  is  divided  into  portions  of  im- 


PRESENTATIONS  OF  THE  FACE. 


319 


equal  length  in  relation  to  the  vertebral  column,  through  which  the 
force  is  ap[)lied,  the  longer  lever  arm  being  toward  the  forehead.  The 
resistance  is  therefore  greatest  toward  the  forehead,  which  remains  behind 
while  the  chin  descends. 

2.  Descent. — As  the  pains  continue  the  head  (the  chin  being  still  in 
advance)  is  ])ropelled  through  the  pelvis.  It  is  generally  said  that  the 
face  cannot  descend,  like  the  occiput,  down  to  the  floor  of  the  pelvis, 
its  descent  being  limited  by  the  length  of  the  neck.  There  is  here, 
however,  an  obvious  misapprehension.  The  neck  from  the  chin  to  the 
sternum,  when  the  head  is  forcibly  extended,  measures  from  3|  to  4 
inches — a  length  that  is  more  than  sufficient  to  admit  of  the  face  descend- 
ing to  the  lower  pelvic  strait.  As  a  matter  of  fact,  the  chin  is  frequently 
observed  in  mento-posterior  positions  to  descend  so  far  that  it  is  appa- 
rently endeavoring  to  pass  the  perineum  before  rotation  occurs.  (At  the 
brim  the  two  sides  of  the  face  are  on  a  level,  but  as  labor  advances  the 
right  cheek  descends  somewhat,  the  caput  succedaneum  forms  on  the 
malar  bone,  and,  if  a  secondary  caput  succedaneum  form,  on  the  cheek.) 

3.  Rotation  is  by  far  the  most  important  point  in  the  mechanism  of 
face  presentations,  for  unless  it  occurs  delivery,  with  a  full-sized  head 
and  an  average  pelvis,  is  practically  impossible.  There  are,  no  doubt, 
exceptions  to  this  rule  which  must  be  separately  considered,  but  it  is  cer- 
tain that  the  absence  of  rotation  is  always  a  grave  and  formidable  com- 

Fi&.  115. 


Rotation  Forward  of  Chin. 


plication  of  face  presentation.  Fortunately,  it  is  only  very  rarely  that 
this  is  not  effected.  The  mechanical  causes  are  precisely  those  which  pro- 
duce rotation  of  the  occiput  forward  in  vertex  presentations.  l*Vs  it  is  ac- 
complished, the  chin  passes  under  the  arch  of  the  ])ubes  and  the  occiput 
rotates  into  the  hollow  of  the  sacrum  (Fig.  115) ;  and  then  commences —  , 


320  LABOR. 

4.  Flexion,  a  niovcincnt  ^vlli(•ll  corresponds  to  extension  in  vertex 
cases.  The  chin  passes  as  i'ar  as  it  can  nndcr  the  pu])ic  arch,  and  there 
becomes  fixed.  The  uterine  force  is  now  expended  on  the  occiput,  which 
revolves,  as  it  were,  on  its  trausvei'se  axis  (Fig.  116),  the  under  surface 

Fig.  IIG. 


Passage  of  the  Head  through  the  External  Parts  in  Face  Presentation. 

of  the  chin  resting  on  the  pubes  as  a  fixed  point.  This  movement  goes 
on  until  at  last  the  face  and  occiput  sweep  over  the  distended  peri- 
neum. 

5.  External  rotation  is  precisely  similar  to  that  which  takes  place 
in  head  presentations,  and,  like  it,  depends  on  the  movements  imparted 
to  the  shoulders. 

Such  is  the  natural  course  of  delivery  in  the  vast  majority  of  cases; 
but  in  order  fully  to  understand  the  subject  it  is  necessary  to  study  those 
rare  cases  in  which  the  chin  points  backward  and  forward  rotation  does 
not  occur.  These  may  be  taken  to  correspond  to  the  occipito-postcrior 
positions,  in  which  the  face  is  born  looking  to  the  jmbcs  ;  l)ut,  unlike 
them,  it  is  only  very  exceptionally  that  delivery  can  be  naturally  com- 
pleted. The  reason  of  this  is  obvious,  for  the  occiput  gets  jammed 
behind  the  pubes,  and  there  is  no  space  for  the  fronto-mental  diameter 
to  pass  the  antero-])Ostcrior  diameter  of  the  outlet  (Fig.  117).  (^^  Cases 
are  indeed  recorded  in  Avhich  delivery  has  been  cifected  with  the  chini 
Vj  looking  posteriorly ;  but  there  is  every  reason  to  believe  that  this  canj 
only  happen  when  the  head  is  either  unusually  small  or  the  ]ielvis  un- 
usually large. N  In  such  cases  the  forehead  is  pressed  down  until  a  portion ' 
appears  at  thc*^ ostium  vaginre,  when  it  becomes  firmly  fixed  behind  the 
pubes,  and  the  chin  after  many  efforts  slips  over  the  jierineum.  AMien 
this  is  effected  flexion  occurs,  and  the  occiput  is  expelled  without  diffi- 
culty. The  forehead  is  probably  always  on  a  lower  level  than  the 
chin. 


PRESENTATIONS  OF  THE  FACE.  821 

Dr.  Hicks '  has  published  a  paper  in  which  he  attempts  to  show  that 
this  termination  of  face  presentations  is  not  so  rare  as  is  generally  sup- 
posed, and  he  gives  a  single  instance  in  which  he  effected  delivery  with 
the  forceps;  but  he  practically  admits  that  special  conditions  are  neces- 
sary, such  as  the  "  antero-posterior  diameter  of  the  outlet  particularly 

Fig.  117. 


Illustrating  the  Position  of  the  Head  when  Forward  Rotation  of  the  Chin  does  not  take  place. 

ample"  and  a  diminished  size  of  the  head.  When  delivery  is  effected 
it  is  probable,  as  Cazeaux  has  pointed  out,  that  the  face  lies  in  the 
oblique  diameter  of  the  outlet,  and  that  the  chin  depresses  the  soft 
structures  at  the  side  of  the  sacro-ischiatic  notch,  which  yield  to  the  ex- 
tent of  a  quarter  of  an  inch  or  more,  and  thereby  permit  the  passage  of 
the  occipito-mental  diameter  of  the  head.  It  must,  however,  be  borne 
well  in  mind  that  spontaneous  delivery  in  men  to-posterior  positions  is 
the  rare  exception,  and  that,  supposing  rotation  does  not  occur — and  it 
often  does  so  at  the  last  moment — artificial  aid  in  one  form  or  another 
will  be  almost  certainly  required. 

Prognosis  of  Face  Presentations. — As  regards  the  mother,  in  the 
great  majority  of  cases  the  prognosis  is  favorable,  but  the  labor  is  apt  to 
be  prolonged,  and  she  is  therefore  more  exposed  to  the  risks  attending 
tedious  delivery.  (As  regards  the  child,  the  prognosis  is  much  more 
unfavorable  than  in  vertex  presentations.  Even  when  the  anterior 
rotaTTorTof  the  chin  takes  place  in  the  natural  Avay,  it  is  estimated  that 
1  out  of  10  children  is  stillborn,  while  if  not  tlie  death  of  the  child  is 
almost  certain.  This  increased  infantile  mortality  is  evidently  due  to 
the  serious  amount  of  pressure  to  which  the  child  is  subjected,  and 
])robably  depends  in  many  cases  on  cerebral  congestion  produced  by 
pressure  on  the  jugular  veins,  as  the  neck  lies  in  the  pelvic  cavity. 
Even  when  the  child  is  born  alive  the  face  is  always  greatly  swollen]' 
and  disfigured.     In  some  cases  the  deformity  produced  in  this  way  is 

1  Ohstet  Trans.,  18G6,  vol.  vii.  p.  57. 
21 


322  LABOR. 

excessive,  aiul  the  features  are  often  scaroely  recoornizable.  This  di.sfio;- 
uration  ])assL's  away  in  a  iew  days,  hut  the  practitioner  should  he 
aware  of  tlie  probahility  of  its  occurrence,  and  should  warn  the 
friends,  or  they  ini*iht  lie  unnecessarily  alarmed  and  possibly  niiirlit 
lay  the  l)lanie  on  him. 

Treatment. — Alter  what  has  been  said  as  to  the  mechanism  of  de- 
livery in  face  presentation,  it  is  obvious  that  the  proper  course  is  to 
leave  the  case  alone,  in  the  expectation  of  the  natural  efforts  bein^ 
sufficient  for  com])lcte  delivery.  Fortunately,  in  the  large  majority  of 
cases  this  course  is  attended  by  a  successful  result. 

The  older  accoucheurs,  as  has  been  stated,  thought  active  interference 
absolutely  essential,  and  recommended  either  podalic  version  or  the 
attempt  to  convert  the  case  into  a  vertex  })resentation  by  inserting 
the  hand  and  bringing  down  the  occiput.  The  latter  ]dan  was  re- 
connnended  by  Baudelocque,  and  is  even  yet  follo^^■ed  by  some 
accoucheurs.  Thus  Dr.  Hodge ^  advises  it  in  all  cases  in  which  face 
presentation  is  detected  at  the  brim;  but,  although  it  might  not  have 
been  attended  with  evil  consequences  in  his  exj^ericnccd  hands,  it  is 
certainly  altogether  unnecessary,  and  would  infallibly  lead  to  most 
serious  results  if  generally  adopted.  It  may,  however,  be  allowable  in 
certain  cases  in  which  the  face  remains  above  the  brim  and  refuses  to 
descend  into  the  pelvic  cavity.  Even  then  it  is  questionable  whether 
podalic  version  should  not  be  preferred,  as  being  easier  of  performance, 
giving,  when  once  effected,  a  much  more  complete  control  over  delivery 
and  being  less  })ainful  to  the  mother.  Version  is  certainly  })rcferal)le 
to  the  application  of  the  forceps,  which  is  introduced  with  difficulty  in 
so  high  a  position  of  the  face,  and  docs  not  take  a  secure  hold,  provided 
the  face  has  not  emerged  from  the  mouth  of  the  uterus.  If  it  has 
passed  through  the  cervix,  version  could  not  be  effected  Avithout  serious 
risk  of  rupture  of  the  uterus. 

Schatz^  has  more  recently  suggested  the  rectification  of  face  presenta- 
1  tions  at  an  early  stage,  before  the  rupture  of  the  membranes,  by  manij)- 
lulation  through  the  abdomen.  He  raises  the  fretal  body  by  ]>rcssure  on 
the  shoulder  and  breast  through  the  abdominal  wall  by  one  hand,  while 
the  breech  is  raised  and  steadied  by  the  other.  By  this  means  the 
occi]nit  is  elevated,  and  then  the  breech  is  jiresscd  downward,  when 
head  flexion  is  produced  by  the  resistance  of  the  ])elvic  walls.  Of 
this  method  I  have  had  no  ])ractical  exjierience,  l)ut  it  obviously 
requires  an  unusual  amount  of  skill  and  practice  in  abdominal  pal- 
])ation. 

When  once  the  face  has  descended  into  the  pelvis,  difficulties  may 
arise  from  two  chief  causes — uterine  inertia  and  non-rotation  foi'ward 
of  the  chin. 

The  treatment  of  the  former  class  must  be  based  on  ]>reeiscly  the 
same  general  i)rinci]iles  as  in  dealing  Avith  proti-acted  labor  in  vertex 
})resentatious.  The  forceps  may  be  applied  with  advantage,  bearing  in 
mind  the  necessity  of  getting  the  chin  under  the  jnibes,  and,  when  this 
has  been  effected,  of  directing  the  traction  forward,  so  as  to  make  the 
occiput  slowly  and  gradually  distend  and  sweep  over  the  perineum. 

>  Sydem  of  Obsktrics,  p.  335.  ^  Arch.  f.  Gyn.,  1873,  Bd.  v.  S.  313. 


PRESENTATIONS  OF  THE  FACE.  323 

The  second  class  of"  difficult  face  cases  is  much  luore  inijjortant,  and 
may  try  the  resouvces  of  the  accoucheur  to  the  utmost,  pur  first 
endeavor  must  be,  if  possible,  to  secure  the  anterior  rotation  of  the 
chin.  \  For  this  purpose  various  manoeuvres  are  reconnnended.  vBy 
some  we  are  advised  to  introduce  the  finger  cautiously  into  the  mouth 
of  the  child  and  draw  the  chin  forward  during  a  pain;  by  others,  to 
pass  the  finger  up  behind  the  occiput  and  press  it  backward  during  the 
pain.  tSchroeder  jmints  out  that  the  difficulty  often  depends  on  the  fact 
of  the  head  not  being  sufficiently  extended,  so  that  the  chin  is  not  on  a 
lower  level  than  the  forehead,  and  that  rotation  is  best  promoted  by 
)ressing  the  forehead  upward  with  the  finger  during  a  pain,  so  as  to  | 


I 


piuse  the  chin  to  descend. \  Penrose^  believes  that  non-rotation  is  gener- 
ally caused  by  the  want  oi  a  j)o'mt  cVaiypui  below,  on  account  of  the  face 
being  unable  to  descend  to  the  floor  of  the  pelvis,  and  that  if  this  is 
supplied  rotation  will  take  place.  In  such  cases  he  applies  the  hand  or 
the  blade  of  the  forceps  so  as  to  press  on  the  posterior  cheek.  By  this 
means  the  necessary  point  cVappui  is  given ;  and  he  relates  several  inter- 
esting cases  in  which  this  simple  manoeuvre  was  effectual  in  rapidly 
terminating  a  previously  lengthy  labor.  Any  or  all  of  these  plans  may 
be  tried.  We  must  bear  in  mind  in  using  them  that  rotation  is  often 
delayed  until  the  face  is  quite  at  the  lower  pelvic  strait,  so  that  we  need 
not  too  soon  despair  of  its  occurring.  If,  however,  in  spite  of  these 
manoeuvres  it  does  not  take  place,  what  is  to  be  done  ?  If  the  head  has 
not  passed  through  the  mouth  of  the  uterus,  turning  would  be  the  sim- 
plest and  most  eifectual  plan.  I  have  succeeded  in  delivering  in  this 
way  when  all  attempts  at  producing  rotation  had  failed  ;  but  generally 
the  face  will  be  too  decidedly  engaged  to  render  it  possible.  An 
attempt  might  be  made  to  bring  down  the  occiput  by  the  vectis  or  by  a 
fillet;  but  if  the  face  be  in  the  pelvic  cavity,  it  is  hardly  possible  for  this 
plan  to  succeed.  An  endeavor  may  be  made  to  produce  rotation  by  the 
forceps,  but  it  should  be  remembered  that  rotation"  of  the  face  mechani- 
cally in  this  way  is  very  difficult,  and  much  more  likely  to  be  attended 
with  fatal  consequences  to  the  child  than  when  it  is  effected  by  the  nat- 
ural efforts.  In  using  forceps  for  this  purpose  the  second  or  pelvic 
curve  is  likely  to  prove  injurious,  and  a  short  straight  instrument  is  to. 
be  preferred.  If  rotation  be  found  to  be  impossible,  an  endeavor  may 
be  made  to  draw  the  face  downward,  so  as  to  get  the  chin  over  the 
perineum  and  deliver  in  the  men  to-posterior  position  ;  but  unless  the 
child  be  small  or  the  pelvis  very  capacious  the  attempt  is  unlikely  to 
succeed.  Finally,  if  all  these  means  fail  there  is  no  resource  left  but 
lessening  the  size  of  the  head  by  craniotomy — a  dernier  ressort  Avhich, 
fortunately,  is  very  rarely  required,  but  which  is  certainly  preferable  to 
long-continued  and  violent  endeavors  to  deliver  with  the  chin  pointing 
backward. 

Brow  Presentations. — It  sometimes  happens  that  the  head  is  par- 
tially extended,  so  as  to  bring  the  os  frontis  into  the  brim  of  the  pelvis 
and  form  what  is  described  as  a  "brow  presentation."  Should  the  head 
descend  in  this  manner  the  difficulties,  although  not  insuperable,  are  apt 
to  be  very  great,  from  the  fact  that  the  long  cervico-frontal  diameter  of 

^  Ainer.  Supplement  to  Ohst.  Journ.,  1876-77,  vol.  iv.  p.  1. 


324  LABOR. 

the  1k:u1  is  engaged  in  the  pchic  cavity.  'I'lie  diagnosis  is  not  difficult, 
iur  the  os  fVnntis  will  Ik-  detected  hy  its  rounded  snrlace,  while  the 
anterior  I'ontani-lle  is  within  reach  in  one  direction,  the  orbit  and  root  ot" 
the  nose  in  another, 

\  Fortunately,  in  the  hu'ge  majority  of  cases  the  brow  presentations  are 
spontaneously  converted  into  either  vertex  or  face  presentations  accord- 
ing as  flexion  or  extension  of"  the  head  occurs^  and  these  must  be 
regarded  as  the  desirable  terminations  and  the  oiujk  to  be  favored.  For 
this  pur[)ose  upward  j)ressure  must  be  made  on  one  or  other  extremity 
of  the  presenting  part  during  a  pain,  so  as  to  favor  flexion  or  extension; 
or,  if  the  j)arts  be  sufficiently  dilated,  an  attempt  may  be  made  to  pass 
the  hand  over  the  occiput  and  draw  it  down,  thus  performing  cephalic 
version.  The  latter  is  the  plan  recommended  by  Hcxlge,  who  describes 
the  operation  as  easy.  Long,  in  an  excellent  ])aper  on  this  subject,  has 
given  figures  to  show  that  correction  of  the  malpresentation  by  mani})- 
idation  has  given  better  results  than  any  other  method  of  treatment.^ 
It  is  questionable,  however,  if  a  well-marked  brow  presentation  be  dis- 
tinctly made  out  while  the  head  is  still  at  the  brim,  whether  j)odalic 
version  would  not  be  the  easiest  and  best  operation.  If  the  forehead 
have  descended  too  low  for  this,  and  if  the  endeavor  to  convert  it  into 
either  a  face  or  vertex  presentation  fail,  the  forceps  will  probably  be 
required.  In  such  cases  the  face  generally  turns  toward  the  pubes,  the 
superior  maxilla  becomes  fixed  behind  the  pubic  arch,  and  the  occiput 
sweeps  over  the  perineum.  Very  great  difficulty  is  likely  to  be  experi- 
enced, and  if  conversion  into  either  a  vertex  or  face  presentation  cannot 
be  effected,  craniotomy  is  not  iwlikely  to  be  required. 


CHAPTER  VII. 
DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS. 

A  FEW  -words  may  be  said  in  this  place  as  to  the  management  of 
occipito-posterior  positions  of  the  head,  especially  of  those  in  which 
forward  rotation  of  the  occiput  does  not  take  place.  It  has  already 
been  pointed  out  that  in  the  large  majority  of  these  cases  the  occiput 
rotates  forward  without  any  ]iarticidar  dilHculty,  and  the  labor  termi- 
nates in  the  usual  way,  Avitli  the  occi])ut  emerging  under  the  arch  of  the 
pubcs. 

In  a  certain  number  of  cases  such  rotation  docs  not  occur,  and  diffi- 
culty and  delay  are  apt  to  follow.  The  proportion  of  cases  in  which 
face-to-pubes  terminations  of  occipito-posterior  positions  occur  has  been 
variously  estimated,  and  they  are  certainly  more  common  than  most  of 

'  American  Journal  of  Obstelrics,  1885,  vol.  xviii.  p.  897. 


DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS.  325 

0111"  textbooks  lead  us  to  expect.  Dr.  Uvedalc  West/  who  studied  tlie 
subject  with  great  care,  ibuud  the  hibor  ended  in  this  way  in  79  out  of" 
2585  births,  all  these  deliveries  being  exceptionally  difficult. 

Causes  of  Face-to-Pubes  Delivery. — He  believed  that  forwaixl 
rotation  of  the  head  is  [)revented  by  the  absence  of  flexion  of  the  chin 
on  the  sternum,  so  that  the  long  occipito-frontal  ((TjTTjTTnstead^oFIhe 
short  subocci])ito-breguiatic  (s.o.ii.),  diameter  of  the  head  is  ])rought 
into  contact  with  the  pelvic  diameter ;  hence  the  occi^jut  is  no  longer 
the  lowest  point,  and  is  not  subjected  to  the  action  of  those  causes  which 
produce  forward  rotation.  Dr.  Macdonald,  who  has  written  a  thought- 
ful paper  on  the  subject,^  believes  that  the  non-rotation  forward  of  the 
occiput  is  chiefly  due  to  the  lai'ge  size  of  the  head,  in  consequence  of 
which  "  the  forehead  gets  so  wedged  into  the  pelvis  anteriorly  that  its 
tendency  to  slacken  and  rotate  forward  does  not  come  into  play."  Dr. 
West's  explanation,  which  has  an  important  bearing  on  the  management 
of  these  cases,  seems  to  explain  most  correctly  the  non-occurrence  of 
the  natural  rotation. 

The  important  question  for  us  to  decide  is,  How  can  we  best  assist  in 
the  management  of  cases  of  this  kind  when  difficulties  arise  and  labor 
is  seriously  retarded? 

Mode  of  Treatment  of  Such  Cases. — Dr.  West,  insisting  strongly 
on  the  necessity  of  complete  flexion  of  the  chin  on  the  sternum,  advises 
that  this  should  be  favored  by  upward  pressure  on  the  frontal  bone, 
with  the  view  of  causing  the  chin  to  approach  the  sternum  and  the 
occiput  to  descend,  and  thus  to  come  within  the  action  of  the  agencies 
which  favor  rotation.  Supposing  the  pains  to  be  strong  and  the  fonta- 
nelle  to  be  readily  within  reach,  we  may  in  this  way  very  possibly  favor 
the  descent  of  the  occiput,  and  without  injuring  the  mother  or  increasing 
the  difficulties  of  the  case  in  the  event  of  the  manoeuvre  failing.  The 
beneficial  effects  of  this  simple  expedient  are  sometimes  very  remarkable. 
In  two  cases  in  which  I  recently  adopted  it,  labor,  previously  delayed 
for  a  length  of  time  without  any  apparent  progress,  although  the  pains 
were  strong  and  effective,  was  in  each  instance  rapidly  finished  almost 
immediately  after  the  upward  pressure  was  applied.  The  rotation  of 
the  face  backward  may  at  the  same  time  be  favored  by  pressure  on  the 
pubic  side  of  the  forehead  during  the  pains. 

Others  have  advised  that  the  descent  of  the  occiput  should  be  pro- 
moted by  downward  traction,  applied  by  the  vectis  or  fillet,  The  latter 
is  the  plan  specially  advocated  by  Hodge  ;^  and  the  fillet  certainly  finds 
one  of  its  most  useful  applications  in  cases  of  this  kind,  as  being  simpler 
of  ap]>lieation  and  probably  more  effective  than  the  vectis. 

Although  any  of  these  methods  may  be  adopted,  a  word  of  caution 
is  necessary  against  prolonged  and  over-active  endeavors  at  producing 
flexion  and  rotation  when  these  seem  delayed.  All  who  have  watched 
such  cases  must  have  observed  that  rotation  often  occurs  spontaneous- 
ly at  a  very  advanced  period  of  labor,  long  after  the  head  has  been 
pressed  down  for  a  considerable  time  to  the  very  outlet  of  the  pelvis, 
and  when  it  seems  to  have  been  making  fruitless  endeavors  to  emerge, 

'■  Cranial  Presentations,  p.  33.  ^  Edin.  Med.  Journ.,  -vol.  1874-75,  p.  3()2. 

^  Sydcm  of  Obstetrics,  p.  308. 


326  LABOR 

yo  lliat  a  liltli'  ])ationcc  \vill  oi'tcn  Ije  sufficient  to  overcome  llie 
ditliciilty. 

In  the  event  of"  assistance  being-  absolnlely  re(juired  there  is  noreas(»ii 
\\\\\  the  Ibrccps  should  not  he  used.  Tlie  instrument  is  not  nioreditticult 
to  ajtply  tiian  under  ordinary  circnnistances,  nor,  as  a  I'ule,  is  nnich  more 
traction  necessary.  Dr.  Mac(U)nald,  indeed,  in  the  paper  ah'eady  alhided 
to  maintains  that  in  persistent  occij)ito-})osterioi'  ]K)sitions  tliere  isahnost 
always  a  M'ant  of  proportion  between  the  head  and  the  pelvis,  and  that 
therefore  the  forceps  will  be  generally  required ;  and  he  i)refers  it  to 
any  artificial  attempts  at  rectification.  Some  p(>culiarities  in  the  mode  of 
tlelivery  are  necessiny  to  bear  in  mind.  In  most  Avcjrks  it  is  taught  that 
the  operator  should  pay  special  attention  to  the  rotation  of  the  head, 
and  should  endeavor  to  im})art  this  movement  by  turning  the  occiput 
forward  during  extraction.  Thus,  Tyler  Smith  says:  "In  delivery 
with  the  forcejis  in  occipito-posterior  presentations  the  head  should  be 
slowly  rotated  during  the  process  of  extra(;tion  so  as  to  bring  the  vertex 
toward  the  pubic  arch,  and  thus  convert  them  into  occipito-anterior 
presentations."  The  danger  accompanying  any  forcible  attemi)t  at 
artificial  rotation  /vill,  however,  be  evident  on  slight  consideration. 
It  is  true  that  in  many  cases  ^vhen  simple  traction  is  applied  the 
occiput  will  of  itself  rotate  forward,  carrying  the  instrument  with  it. 
But  that  is  a  very  diiferent  thing  from  forcibly  twisting  round  the 
head  with  the  blades  of  the  forceps,  without  any  assurance  that  the 
body  of  the  child  will  follow  the  movement.  It  is  im])ossible  to  con- 
ceive that  such  violent  interference  should  not  be  attended  with  serious 
risk  of  injury  to  the  neck  of  the  child.  If  rotation  do  not  occur,  the 
fair  inference  is  that  the  head  is  so  placed  as  to  render  delivery  with  the 
face  to  the  pubes  the  best  termination,  and  no  endeavor  should  be  made 
to  prevent  it.  This  rule  of  leaving  the  rotation  entirely  to  nature,  and 
using  traction  only,  has  received  the  a}i])r()val  of  Barnes  and  most 
modern  authorities,  and  is  the  one  which  recommends  itself  as  the 
most  scientific  and  reasonable. 

There  are  cases  in  which  the  pelvic  curve  of  the  forceps  is  of  doubt- 
ful utility.  When  applied  in  the  usual  way  the  convexity  of  the  blades 
])oints  backward.  If  rotation  accompany  exti-action,  the  blades  neces- 
sarily follow  the  movement  of  the  head  and  their  convex  edges  will 
turn  forward.  It  certainly  seems  probable  that  such  a  movement 
M'ould  subject  the  maternal  soft  parts  to  considerable  risk.  I  have, 
however,  more  than  once  seen  such  rotation  of  the  instrument  happen 
Avithout  any  apparent  bad  result ;  but  the  dangers  are  obvious.  Hence 
it  would  be  a  wise  precaution  either  to  use  a  pair  of  straight  forceps  for 
this  particular  operation,  or  to  remove  the  blades  and  leave  the  case  to 
be  terminated  by  the  natural  powers  when  the  head  is  at  the  lower  strait 
and  rotation  seems  about  to  occur.  Prof.  Ilichardson  ^  advises  that 
when  the  forceps  is  applied  in  persistent  occipito-posterior  positions  it 
should  be  introduced  with  the  pelvic  curve  reversed.  He  claims  for 
this  method  that  the  traetic^n  is  chiefly  exerted  on  the  occi])ut,  where  it 
is  most  needed,  which  thereby  descends  and  produces  the  necessary 
flexion  of  the  chin  on  the  sterninn.     The  forceps  is  then  removed,  and, 

^  Medical  Communications  of  (he  Massachusetts  Medical  Society,  1885,  vol.  xiii.  No.  4. 


DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS.  327 

if  tlic  pains  are  sufficient,  rotation  ibrward  is  sure  to  take  ])]ace.  Of 
this  plan  I  have  no  personal  experience.  When  there  is  no  rotation 
more  than  usual  care  should  be  taken  Avith  the  perineum,  which  is 
necessarily  much  stretched  by  tlu.'  rounded  occiput.  Indeed,  the  risk 
to  the  perineum  is  very  considerable,  and  even  with  the  greatest  care 
it  may  be  impossible  to  avoid  laceration. 

Bearing  these  precautions  in  mind,  delivery  with  the  forceps  in 
occipito-]>osterior  positions  offers  no  special  difficulties  or  dangers. 

[Version  by  the  Vertex. — The  following  are  the  teachings  of  sev- 
eral eminent  American  obstetricians  upon  the  management  of  occipito- 
posterior  positions : 

1.  "In  primitive  oblique  occipito-posterior  positions  of  the  head 
nature  will  almost  without  exception  cause  spontaneous  rotation  of  the 
occiput  to  the  symphysis  pubis ;  but  to  favor  this  movement  the  bag  of 
waters  should  be  preserved." 

2.  "  Spontaneous  rotation,  as  a  rule,  does  not  begin  until  the  head 
meets  with  resistance  from  the  floor  of  the  pelvis  :  hence  no  effort  to 
force  rotation  should  be  made  until  nature  has  proved  herself  inade- 
quate." 

3.  "  Where  rotation  forward  is  prevented,  it  is  probably  due  to  the 
l)Osition  of  the  occiput  having  been  originally  directly  backward,  and 
only  becoming  oblique  after  the  descent  of  the  head  into  the  pelvis,  the 
position  of  the  child's  body  preventing  the  anterior  movement  of  its 
occiput ;  that  is,  the  sixth  position  of  Hodge  has  changed  into  a  fourth 
or  fifth,  but  will  not  without  assistance  become  a  first  or  second." 

4.  "  If,  then,  rotation  is  not  spontaneous  after  the  head  reaches  the 
floor  of  the  pelvis,  version  by  the  vertex  will  not  take  place,  except  it 
be  forced  by  the  vectis  or  forceps." 

Use  of  the  Hand  in  Occipito-posterior  Positions. — The  introduc- 
tion of  the  hand  for  the  purpose  of  effecting  version  by  the  vertex  was 
strongly  advocated  by  the  late  Dr.  John  S.  Parry  of  Philadelphia, 
whose  hand  was  very  small  and  thin,  and  could  be  used  to  great  advan- 
tage. Prof.  Ottavio  Morisani  of  Naples  is  said  to  use  his  Avith  even 
greater  success,  because  of  its  smaller  size.  Large  hands  should  not  be 
used  in  primiparse.  By  this  mancBuvre  I  once  brought  an  occiput  under 
the  pubic  arch  of  a  primipara  in  three  pains,  after  she  had  labored  for 
hours  to  deliver  herself. — Ed.] 


328  LABOR. 


al 


CHAPTER   VITI. 

PRESENTATIONS  OF  THE  SHOULDER,  ARM,  OR  TRUNK.— COMPLEX 
PRESENTATIONS.— PROLAPSE  OV   THE  FUNIS. 

In  the  prcscntatiftus  already  considered  the  lung  diameter  ol'  the  la'- 
tu.s  corresponded  Avith  that  of  tlie  uterine  cavity,  and  in  all  of  them  the 
birth  of  the  child  by  the  maternal  efforts  was  the  general  and  normal 
termination  of  labor.  We  have  now  to  discuss  those  im])ortant  cases  in 
which  the  long  diameter  of  the  ftctus  and  uterus  do  not  corresjxjud,  but 
in  which  the  long  fo'tal  diameter  lies  obliquely  across  the  uterine  cavity. 
In  the  large  majority  of  these  it  is  either  the  shoulder  or  some  j)art  of 
the  upper  extremity  that  presents;  for  it  is  an  admitted  fact  that 
although  other  parts  of  the  body,  such  as  the  back  or  alxlomen,  may  in 
exceptional  cases  lie  over  the  os  at  an  early  period  of  laljor,  yet  as  labor 
progresses  such  presentations  are  almost  always  converted  into  those  oi" 
the  upper  extremity. 

For  all  practical  purposes  we  may  confine  ourselves  to  a  consideration 
of  shoulder  presentations,  the  further  subdivision  of  these  into  dboir  or 
hand  presentations  being  no  more  necessary  than  the  division  of  })elvic 
presentations  into  breech,  knee,  aud  footling  ca.ses,  since  the  mechanism 
and  management  are  identical  whatever  part  of  the  uj^per  extremity 
presents. 

There  is  this  great  distinction  betM'een  the  presentations  we  are  now 
considering  and  those  already  treated  of,  that  on  account  of  the  rela- 
tions of  the  foetus  to  the  pelviSjTleli  very  by  the  natural  powers  is  impos- 
sible except  under  sj^ecial  ana  very  unusual  circumstances  that  i-an 
never  be  relied  upon.\  Intervention  on  the  part  of  the  accoucheur  is 
therefore  absolutely  essential,  and  the  safety  of  both  the  mother  and 
child  depends  upon  the  early  detection  of  the  abnormal  position  of  the 
foetus ;  for  the  necessary  treatment,  which  is  comparatively  easy  and 
safe  before  labor  has  been  long  in  progress,  becomes  most*difficult  and 
hazardous  if  there  have  been  nuich  delay. 

Position  of  the  Foetus. — Presentations  of  the  ujiper  extremity  or 
trunk  are  often  spoken  of  as  ''transverse  presentations"  or  "  cross- 
births  ;"  but  l)oth  of  these  terms  are  misleading,  as  they  imply  thaftlie 
ffctus  is  placed  transversely  in  the  uterine  cavity  or  that  it  lies  directly 
across  the  ])elvic  brim.  (  As  a  matter  of  fact,  this  is  never  the  case,  for 
the  child  lies  (il)li(|ncly  in  the  uterus — not  indeed  in  its  long  axis,  but 
in   oiic   iiitcniicdiiiic  between  its  long  and  transverse  diameters.^ 

^Two  great  divisions  of  shoulder  presentati(»ns  are  recognized — the  one 
in  whicli  the  back  of  the  child  looks  to  the  abdomen  of  the  mother, 
(Fig.  118),(and  the  other  in  which  the  back  of  tiie  child  is  turned 
toward  the  sjiine  of  the  mother  (Fig.  119)))  |  Each  of  these  is  subdivided 
into  two  sui)sidiarv  classes,  according  as  the  head  of  the  child  is  jilaced 
in  the  right  or  left  iliac  fossa.     Thus  in  dorso-anterior  position.s,  if  the 


FRESENTATIOXS  OF  THE  SHOULDEM,  ETC. 

head  lie  in  the  left  iliac  fossa  (left  scapula-anterior — scapula-lseva 
rior,  S.L.A.),  the  right  shoulder  of  the  child  presents ;  if  in  the 

Fig.  118. 


329 


ante-j 
righfl 


Dorso-anterior  Presentation  of  the  Arm  (s.l.a.). 


iliac  fossa  (right  scapula-anterior — scapula-dextra  anterior,  s.d.a.),  the  | 
left.     So  iu  dorso-posterior  positions,  if  the  head  lie  in  the  left  iliac  1 


Fig.  119. 


Dorso-posterior  Presentation  of  the  Arm  (s.d.a.). 

fossa  (left  scapula-posterior — scapula-lfieva  posterior,  s.l.p.),  the  left  ,. 
.shoulder  presents;  if  iu  the  right^the  right  (right  scapula-posterior —  y 
scapula-dextra  posterior,  s.D.p.y  |  Of  the  two  classes  the  dorso-ante-  ' 

'  Left  and  right  refer  in  tliis  nomenclature,  as  in  all  positions,  to  the  left  and  right 
side  of  tlie  mother,  without  regard  to  that  of  the  child. 


330  LABOR. 

rioi'  positions  iirc  nioiv  (•(nniiion,  in  tlio  jiroportion,  it  is  said,  of"  two 
to  ouc.l 

The  Causes  of  sIiouKUt  jji-csentatiun  are  not  well  known.  Amongst 
those  most  commonly  mentioned  are  prematurity  of  the  ia-tus  and*cxeess 
of  hquor  anniii ;  either  of  these,  by  inereiising  the  mobility  of  the  ftetus 
in  idcro,  Mould  probably  have  consi(leral)le  iiifluenee.  ('Jlie  fact  that  it 
occurs  much,  more  frequently  amoniList  ])remature  births  has  lono-  been 
recoonized./-^ Undue  obliquity  of  the  uterus  has  prolxibly  some  influence, 
since  tlie  early  ])ains  might  cause  the  presenting  part  to  hitch  against  the 
pelvic  brim  and  the  shoulder  to  descend.  An^)unusually  low  attach- 
ment of  the  ])Iacenta  to  the  inferior  segment  of  the  uterine  cavity  has 
been  mentioned  as  a  j)redisposing  cause.  In  consequence  of  this  the 
head  does  not  lie  so  readily  in  the  lower  uterine  segment,  and  is  apt  to 
slip  up  into  one  of  the  iliac  fosste.  This  is  sui)posed  to  explain  the  fre- 
quency of  arm  presentations  in  cases  of  partial  or  complete  placenta 
prsevia.  Danyau  and  Wigand  believe  that  shoulder  presentations  are 
favored  by  irregularity  in  the  shape  of  the  uterine  cavity,  especially  a 
relative  increase  in  its  trar^verse~cnanieFe]\  Tins' tlieoryllas  been  gen- 
erally discredited  by  "writers,  and  it  is  certainly  not  susceptil)le  of  proof; 
but  it  seems  far  from  unlikely  that  some  peculiarity  of  shape  may  exist, 
not  capable  of  recognition,  but  sufficient  to  influence  the  position  of  the 
foetus.  How  otherwise  are  Ave  to  explain  those  remarkable  cases,  many 
of  which  are  recorded,  in  which  similar  malpositions  occurred  in  many 
successive  labors  ?  Thus,  Joulin  refers  to  a  ])atient  who  had  an  arm 
presentation  in  three  successive  pregnancies,  and  to  another  who  had  a 
shoulder  })resentation  in  three  out  of  four  labors.  Certainly,  such  con- 
stant recurrences  of  the  same  abnormality  could  only  be  explained  on 
the  hypothesis  of  some  very  persistent  cause  such  as  that  referred  to. 
Pinard^  states  that  shoulder  presentations  are  seven  times  more  common 
in  multipara  than  in  primiparse,  in  consequence,  as  he  believes,  of  the 
'laxity  of  the  abdominal  walls  in  the  former,  which  allows  the  uterus  to 
fall  forward,)  and  thus  prevents  the  head  entering  the  pelvic  brim 
in  the  latter  weeks  of  pregnancy.  It  is  probable  that  merely  accidental 
causes  have  most  influence  in  the  production  of  shoulder  presentations, 
such  as  falls  or  undue  pressure  exerted  on  the  abdomen  by  badly-htting 
'^•sJ  or  tight  stays.  Partiall}^  transverse  positions  during  pregnancy  are  cer- 
J  tainly  much  more  common  than  is  generally  believed,  and  may  often  be 
^•.  detected  by  abdominal  palpation.  The  tendency  is  for  such  malpo- 
sitions to  be  righted  either  before  labor  sets  in  or  in  the  early  period  of 
labor ;  but  it  is  quite  easy  to  understand  how  any  persistent  jiressure, 
aj)plied  in  the  manner  indicated,  may  perpetuate  a  position  which  other- 
wise would  have  been  only  temporary. 

Prognosis  and  Frequency. — According  to  Churchill's  statistics, 
shoulder  prescntati(jns  occur  about  once  in  2G0  cases;  that  is,  only 
slightly  less  frequently  than  those  of  the  faceTTThe  ]}rognosis  to  both 
the  mother  and  child  is  much  moi-e  unfiivorablel  for  he  estimates  that 
out  of  235  cases,  T  in  9  oF  tlie  inotliers'aiid  naif  the  children  Avere 
lost.  The  ])rognosis  in  each  individual  case  will,  of  course,  vary  much 
with  the  period  of  delivery  at  which  the  mali)osition  is  recognized.     If 

*  Annul.  d'Hij(j.  Pub.  ei  de  Med.,  Jan.,  1879. 


PBESENTATTONS  OF  THE  SHOULDER,  ETC.  331 

detected  early,  interference  is  easy  and  tlie  prognosis  onglit  to  be  good; 
whereas  there  are  few  obstetric  dithcnlties  more  trying  than  a  case  of 
shoulder  presentation,  in  which  the  necessary  treatment  has  been  delayed 
until  the  presenting  part  has  been  tightly  jammed  into  the  cavity  of  the 
pelvis. 

Diagnosis. — Bearing  this  fact  in  mind,  the  paramount  necessity  of  an 
accurate  diagnosis  will  be  apparent;  and  it  is  specially  important  tliat  we 
should  be  able  not  only  to  detect  that  a  shoulder  or  arm  is  })resenting, 
but  that  we  sliould,  if  possible,  determine  which  it  is  and  how  the  body 
and  head  of  the  child  are  placed.  The  existence  of  a  shoulder  presen- 
tation is  not  generally  suspected  until  the  first  vaginal  examination  is 
made  during  labor.  The  practitioner  will  then  be  struck  with  the 
absence  of  the  rounded  mass  of  the  foetal  head,  and,  if  the  os  be  opened 
and  the  membranes  protruclTng,  Tn^'tlTeii'elongated  form,  which  is  com- 
mon to  this  and  to  other  malpresentations.  f  If  the  presenting  part  be| 
too  high  to  reach,  as  is  often  the  case  at  an  early  period  of  labor,  an| 
endeavor  should  at  once  be  made  to  ascertain  the  foetal  position  by* 
abdominal  examiuation.'^t  This  is  the  more  important  as  it  is  much  more 
easy  to  recognize  presentations  of  the  shoulder  in  this  way  than  those  of 
tlie  breech  or  foot(  and  at  so  early  a  period  it  is  often  not  only  possible, 
but  comparatively  easy,  to  alter  the  position  of  the  foetus  by  abdominal 
manipulation  alone,\  and  thus  avoid  the  necessity  of  the  more  serious 
form  of  version.  The  method  of  detecting  a  shoulder  presentation  by  ex- 
amination of  the  abdomen  has  already  been  described  (p.  127),  and  need 
not  be  repeated.  The  chief  points  to  look  for  are — the  altered  shape' 
of  the  uterus  ami  twosolid  JMIses,  the  head  and  the  breech,  one  in 
either  iliac  fossa.)  The  facility  with  which  these  parts  may  be  recog- 
nized varies  much  in  different  patients.  In  thin  women  with  lax  ab- 
dominal parietes  they  can  be  easily  felt,  while  in  very  stout  women  it  may 
be  impossible.  Failing  this  method,  we  must  rely  on  vaginal  examina- 
tions, although  before  the  membranes  are  ruptured  and  when  the  pre- 
senting part  is  high  in  the  pelvis  it  is  not  always  easy  to  gain  accurate 
information  in  this  way.  The  difficulty  is  increased  by  the  paramount 
importance  of  retaining  the  membranes  intact  as  long  as  possible.  It 
should  be  remembered,  therefore,  that  when  a  presentation  of  the 
suj^erior  extremity  is  suspected,  the  necessary  examinations  should  only 
be  made  in  the  intervals  between  the  pains  when  the  membranes  are  lax, 
and  never  when  they  are  rendered  tense  by  the  uterine  contractions. 

As  either  the  shoulder,  the  elbow,  or  the  hand  may  present,  it  will  be 
best  to  describe  the  peculiarities  of  each  sejjarately,  and  the  means  of 
distinguishing  to  which  side  of  the  body  the  presenting  part  belongs. 

1.  The  shoulder  is  recognized  as  a  round,  smooth  prominence,  at 
one  point  of  which  may  often  be  felt  the  sharp  edge  of  the  acromion. 
If  the  finger  can  be  passed  sufficiently  high,  it  may  be  possible  to  feel 
the  clavicle  and  the  spine  of  the  scapula.  A  still  more  complete  exami- 
nation may  enable  us  to  detect  the  ril^  and  the  intercostal  spaces,  M-hicli 
would  be  quite  conclusive  as  to  the  nature  of  the  presentation,  since 
there  is  nothing  resembling  them  in  any  other  part  of  the  bodv.  At 
the  side  of  the  shoulder  the  hollow  of  the  axilla  mav  aenerallv  be  made 
out. 


332  LABOR. 

In  order  to  ascertain  the  position  of  the  cliiid  we  liave  to  find  <»ut  in 
Avliich  iliac  fossa  the  head  lies.  This  may  be  done  in  two  ways:  1st,  the 
head  may  be  I'elt  throngh  the  ab(]oniinal  parietcs  J^j^4}ajj)^  and,  2d, 
since  the  axilla  aj\va\-s  points  toward  the  feet,  if  it  point  to  the  left  side 
the  head  nuist  lie  m  tlie  riij^Titlliae  fossa;  if  to  the  riffht,  the  head  mnst 
be  placed  in  the  left  iliac  fossa.  (Again,  the  S])ine  of  the  sea])nla  nnist 
correspond  to  the  back  of  the  child,  the  clavicle  to  its  abdomen  ,j  and, 
by  feeling  one  or  other  Me  know  whether  we  liave  to  do  with  a  uoi-so- 
antcrior  or  dorso-posterior  position.  If  we  cannot  satisfactorily  de- 
termine the  position  by  these  means,  it  is  quite  legitimate  practice  to 
(bring  down  the  arm  carefully,  jirovided  the  membranes  are  i-uptiu'cd, 
so  as  to  examine  the  hand,  Mhich  will  be  easily  recognized  as  right 
or  left.  \  This  expedient  will  decide  the  point;  but  it  is  quc  Avhich 
it  is  better  to  avoid  if  possible,  for  it  not  only  slightly  increases  the 
difficulty  of  turning,  altliougli  perhaps  not  very  materially,  but  the 
arm  might  possibly  be  injured  in  the  endeavor  to  bring  it  down. 

The  only  part  of  the  body  likely  to  be  taken  for  the  shoulder  is 
the  breech ;  but  in  that  its  larger  size,  the  groove  in  mIhcIi  the 
genital  organs  lie,  the  second  prominence  formed  by  the  other  but- 
tock, and  the  sacral  spinous  processes  are  sufficient  to  prevent  a  mis- 
take. 

2.  The  elbo-w  is  rarely  felt  at  the  os,  and  may  be  readily  recognized 
by/the  sharj)  prominence  of  the  olecranon,  situated  between  two  lesser 
prominences,  the  condyles.\  As  the  elbow  always  jjoiuts  toward  the  feet:, 
the  ])ositiou  of  the  fcetus  Gnu  be  easily  ascertained. 

3.  The  hand  is  easy  to  recognize,  and  can  only  be  confounded  with 
the  foot.  It  can  be  distinguished  by  its  borders  being  of  the  same 
thickness,  by  the  fingers  being  wider  ajiart  and  more  readily  se|)arated 
from  each  other  than  the  toes,  and  aljove  all  by  the  mobility  of  the 
thumb,  which  can  be  carried  across  the  palm  and  placed  in  apposition 
with  each  of  the  fingers. 

It  is  not  difficult  to  tell  which  hand  is  presenting.  If  the  hand  be 
in  the  vagina  or  beyond  the  vulva,  and  within  easy  reach,  we  recognize 
Mhich  it  is  by  laying  hold  of  it  as  if  we  were  about  to  shake  hands.  \  If 
the  palm  lie  in  the  palm  of  the  practitioner's  hand,  with  the  two  thumbs 
in  apposition,  it  is  the  right  hand  ;  if  the  l)ack  of  the  hand,  it  is  the 
left.  ^  Another  siniple  way  is  for  the  practitioner  to  imagine  his  own 
I  hand  placed  in  precisely  the  same  position  as  that  of  tlie  foetus,  and  this 
■  will  readily  enable  him  to  verifv  the  previous  diagnosis.  A  simple  rule 
tells  us  how  the  body  of  the  child  is  placed,  for,  jirovided  we  are  sure  the 
hand  is  in  a  state  of  supination,  the  back  of  the  hand  ])oints  to  the  back 
of  the  child,  the  palm  to  its  abdomen,  the  thund)  to  the  head,  and  the 
little  finger  to  the  feet. 

Mechanism. — It  is  perhaps  hardly  })ro])er  to  talk  of  a  mechanism  of 
shoulder  presentations,  since  if  left  una.ssisted  they  almost  invariably 
lead  to  the  gravest  consequences.  Still,  Nature  is  not  entirely  at  fault 
even  here,  and  it  is  well  to  study  the  means  she  adojits  to  terminate 
these  nial]iositions. 

Terminations  of  Shoulder  Presentation. — There  are  two  possible 


terminations  of  shoulder  presentation,  j  In  one,  known  as  '^spontaneous 


atatii 
flu 


PRESENTATIONS  OF  THE  SHOULDER,  ETC.  333 

version/^  some  other  part  of  the  foetus  is  substituted  for  that  originally 
presenting  in  the  other,  ^^ spontaiieous  evolution,"  the  fcjetus  is  expelled 
by  being^jueezed  through  the  pelvis,  without  the  originally  presenting 
part  being  withdrawn.  It  cannot  be  too  strongly  impressed  on  the  mind 
that  neither  of  these  can  be  relied  on  in  practice. 

Spontaneous  Version.-(-Spontaneous  version  may  occasionally  occur 
before  or  immediately  after  the  rupture  of  the  membranes,  when  the 
foetus  is  still  readily  movable  within  the  cavity  of  the  uterus.)  A  few 
authenticated  cases  are  recorded  in  which  the  same  fortunate  isiue  took 
place  after  the  shoulder  had  been  engaged  in  the  pelvic  brim  for  a  con- 
siderable time,  or  even  after  prolapse  of  the  arm ;  but  its  probability  is 
necessarily  much  lessened  under  such  circumstances.  Either  the  head 
or  the  breech  may  be  brought  down  to  the  os  in  place  of  the  original 
presentation. 

The  precise  mechanism  of  spontaneous  version  or  the  favoring  cir- 
cumstances are  not  sufficiently  understood  to  justify  any  positive  state- 
mput  with  regard  to  it. 

f  Cazeaux  believed 
tion  of  the  uterus. 


remains  inert  or  only 
this  may  effect  spontaneous  version  let  us  suppose  tEat  the  child  is  lying 
with  the  head  in  the  left  iliac  fossa.  Then,  if  the  left  side  of  the  uterus 
should  contract  more  forcibly  than  the  right,  it  would  clearly  tend  to 
push  the  head  and  shoulder  to  the  right  side  until  the  head  came  to 
present  instead  of  the  shoulder.  A  very  interesting  case  is  related  by 
Geneuil,'  in  which  he  was  present  during  spontaneous  version,  in  the 
course  of  which  the  breech  was  substituted  for  the  left  shoulder  more 
than  four  hours  after  the  rupture  of  the  membranes.  In  this  case  the 
uterus  was  so  tightly  contracted  that  version  was  impossible.  He 
observed  the  side  of  the  uterus  opposite  the  head  contracting  ener- 
getically, the  other  remaining  flaccid,  and  eventually  the  case  ended 
without  assistance,  the  breech  presenting.  The  natural  moulding 
action  of  the  uterus,  and  the  greater  tendency  of  the  long  axis  of  the 
child  to  lie  in  that  of  the  uterus,  no  doubt  assist  the  transformation ; 
and  much  must  depend  on  the  mobility  of  the  fcetus  in  any  individual 
case. 

That  such  changes  often  take  place  in  the  latter  weeks  of  pregnancy, 
and  before  labor  has  actually  commenced,  is  quite  certain,  and  they  are 
probably  much  more  frecjuent  than  is  generally  supposed.  When  spon- 
taneous version  does  occur  it  is  of  course  a  most  favorable  event,  and 
the  termination  and  prognosis  of  the  labor  are  then  the  same  as  if  the 
head  or  breech  had  originally  presented. 

Spontaneous  Evolution. — The  mechanism  of  spontaneous  evolution, 
since  it  was  first  clearly  worked  out  by  Douglas,  has  been  so  often  and 
carefully  described  that  we  know  precisely  how  it  occurs.  Although 
every  now  and  then  a  case  is  recorded  in  which  a  living  child  has  been 
born  by  this  means,  such  an  event  is  of  extreme  rarity ;  and  there  is  no 
doubt  of  the  accuracy  oFthe  general  opinion,"tTTaFspontancous  evolution 
can  only  happen   when  the  pelvis  is  unusually  roomy  and  the  child 

^  Ann.  de  Gynicologk',  1876,  vol.  v.  p.  468. 


334 


LABOR. 


small,  ami  that  it  almost  necesstirily  involves  the  death  of  the  frjetus 
ou  aofount  of  the  iimuonse  pressure  to"~\vTH7Ti"Tf'Ts  .^uhjcrtcd. 

Two  varieties  arc  (lescril)ed,  in  one  of  which  the  head  is  fii^t  horu, 
in  the  other  the  breech ;  in  both  the  originally  presenting  arm  remained 
prola})sed.  The  forjiier  is  of  extreme  rarity,  and  is  believed  only  to 
have  hapj)ened  with  very  premature  children  whose  bodies  were  small 
and  flexible,  and  when  traction  had  been  made  on  the  presenting  arm. 
Under  such  circumstances  it  can  hardly  be  called  a  natural  process,  and 
we  may  confine  our  attention  to  the  latter  and  more  common  variety. 

AVhat  takes  })lace  is  as  follows :  the  j)resenting  arm  aud  shoulder 
are  tightly  jammed  down,  as  far  as  possible,  by  the  uterine  contractions, 
and  the  head  becomes  stronglv  flexed  ou  tho  shoulder.^  As  umch  of 


Fig.  1-JU. 


Spontaneous  Evolution,    (.\fter  Cbira.) 
Thia  drawing  was  made  from  a.  iwtient  who  died  undelivered,  the  body  being  frozen  and  bisected. 

the  body  of  the  foetus  as  the  pelvis  will  contain  becomes  engaged,  and 
then  a  movement  of  rotation  occurs  which  brings  the  body  of  the  child 
nearly  into  the  autero-posterior  diameter  of  the  pelvis  (Fig.  120).  The 
shoid'der  projects  under  the  arch  of  the  pubes,  the  head  lying  above  the 
symphysis  and  the  breech  near  the  sacro-iliac  synchondrosis.  It  is 
essentiid  that  tlie  head  should  lie  forward  above  the  pubcs,  so  that  the 


PRESENTATIONS  OF  THE  SHOULDER,  ETC.  335 

length  of  the  neck  may  permit  tlic  .sliouldor  to  project  nnder  the  puhic 
arcli  without  any  part  of  the  head  entering  tlie  pelvic  cavity.  The 
shoulder  and  neck  of  the  child  now  become  fixed  points  round  which 
the  body  of  the  child  rotates,  and  tJic  whole  force  of  the  uterine  con- 
tractions is  expended  on  the  breech.  The  latter,  with  the  body,  there- 
fore becomes  more  and  more  depressed,  until  at  last  the  side  of  the 
thorax  reaches  the  vulva,  and,  followed  by  the  breech  and  inferior 
extremities,  is  slowly  pushed  out.  As  soon  as  the  limbs  are  born  the 
head  is  easily  exj)elied. 

The  enormous  pressure  to  which  the  body  is  subjected  in  this  process 
can  readily  be  understood.  As  regards  the  practical  bearings  of  this 
termination  of  shoulder  presentations,  all  that  need  be  said  is  that  if 
we  should  happen  to  meet  with  a  case  in  which  the  shoulder  and  thorax 
were  so  strongly  depressed  that  turning  w^as  impossible,  and  in  which 
it  seemed  that  nature  was  endeavoring  to  effect  evolution,  we  should  be 
justified  in  aiding  the  descent  of  the  breech  by  traction  on  the  groin 
before  resorting  to  the  difficult  and  hazardous  operation  of  embryotomy 
or  decapitation. 

Treatment. — It  is  unnecessary  to  describe  specially  the  treatment  of 
shoulder  presentation,  since  it  consists  essentially  in  performing  the 
operation  of  turning;,  which  is  fullv  described  elsewhere.  It  is  only 
needful  here  to  insist  on  the  advisability  oi  pertorming  the  operation 
in  tiie  way  which  involves  the  least  interference  with  the  uterus.  Hence 
if  the  nature  of  the  case  be  detected  before  the  membranes  are  ruptured, 
an  endeavor  should  be  made — and  fcught  generally  to  succeed — to  turn 
by  external  manipulation  only.)  If  we  can  succeed  in  bringing  the 
breech  or  head  over  the  os  in  this  way,  the  case  will  be  little  more 
troublesome  than  an  ordinary  presentation  of  these  parts.  Failing  in 
this,  turning  by;  combined  external  and  internal  manipulation]  should 
be  attempted,  and  the  introduction  of  the  entire  hand  should  be  reserved 
for  those  more  troublesome  cases  in  which  tlie~waters  have  long  drained 
away  and  in  which  both  these  methods  are  inapplicable. 

Should  all  these  means  fail,  we  must  resort  to  the  manipulation  of 
the  child  by  embryulcia  or  decapitation,  probably  the  most  difficult  and 
dangerous  of  all  obstetric  operations.  [The  Csesarean  operation  has  been 
performed  in  the  United  States  in  14  cases  where  the  foetus  was  impacted' 
in  a  transverse  position,  with  a  saving  of  10  women,  or  71.3-7  per  cent. 
In  seven  cases  the  arm  protruded  ;  in  three  the  pelvis  was  small ;  and 
in  two  it  was  deformed.  In  three  women  there  were  natural  labors  at 
subsequent  periods.  The  four  deaths  were  produced  as  follows :  Case 
3  was  in  labor  ninety-six  hours,  three  days  under  a  midwife,  and  died 
of  exhaustion  in  seventeen  hours.  Case  7  was  twenty-six  hours '  in 
labor,  and  had  been  under  the  care  of  a  midwife,  who  had  given  ergot 
freely ;  she  was  much  prostrated  and  died  in  twelve  liours.  Case  9 
would  in  all  probability  have  recovered  had  she  not  risen  from  her 
bed  on  the  third  day  to  defend  her  mother  against  her  husband,  who 
came  home  drunk.  The  fright,  excitement,  and  exertion  caused  her 
death  in  a  few  hours.  Case  13  was  three  days  in  labor,  and  ergot  Avas 
largely  used ;  forceps,  version,  and  craniotomy  were  all  tried.  Death 
came  on  the  tenth  day  from  the  bursting  of  an  abscess  of  the  abdomi- 


336  LABOR. 

nal  Nvall  into  the  peritoneal  cavity,  resulting  in  septic  peritonitis.  Case 
11  Mas  ojH'ratcd  ii])(»ii  in  June,  ISSO;  was  up  and  at  Avork  in  a  month  ; 
iR'oainc  pregnant  in  two  and  a  liali'  more,  and  hore  a  child  natnrallv  in 
twelve  and  a  half  months  after  the  operation.  The  uterine  wound  was 
closed  with  two  silver-wire  sutures. 

This  oj)eration  certainly  j)romises  w^cll  in  ca.ses  of  impaction  with  an 
arm  j)rotrudino-  Avhere  there  has  been  no  deforming  pelvic  disease. 
With  the  new  conservative  method  such  cases  should  be  saved  in  large 
pro])ortion  in  the  United  States.  AVill  embryulcia  or  decapitation  be 
likely  to  succeed  as  -weW  in  this  country? — Ed.] 

Complex  Presentations. — There  are  various  so-called  complex  pres- 
entafioits  in  which  more  than  one  part  ()f  jthe  foetal  body  presents. 
Thus  we  may  have  a  hand^or  a  foot  presenting  wTtli  the  head  or  a  foot 
and  hand  presenting  simultaneously.  The  former  do  not  necessarily 
give  rise  to  any  serious  difficulty,  for  there  is  generally  sufficient  r(X)m 
for  the  head  to  pass.  [Indeed,  it  is  unlikely  that  either  the  hand  or  foot 
should  enter  the  pelvic  brim  with  the  head,  unless  the  head  was  unusu- 
ally small  or  the  pelvis  more  than  ordinarily  capacious.  \  As  regards 
treatraentjfit  is  no  doubt  advisable  to  make  an  attempt  to  replace  the 
hand  or  root  by  pushing  it  gently  above  the  head  in  the  intervals 
between  the  pains,  and  to  maintain  it  there  until  the  head  be  fully 
engaged  in  the  pelvic  cavit}-^  The  engagement  of  the  head  can  be 
hastened  by  abdominal  pressure,  which  will  be  of  great  value.  (^Fail- 
ing this,  all  we  can  do  is  to  place  the  presenting  member  at  the  part 
of  the  pelvis  w^here  it  will  least  impede  the  labor  and  be  the  least 
subjected  to  pressure ;  and  that  will  generally  be  opposite  the  temple 
of  the  child)  As  it  nuist  obstruct  the  passage  of  the  head  to  a  certain 
extent,  the  application  of  the  forceps  may  be  necessary.  "When  the  feet 
and  hands  present  at  the  same  time,  in  addition  to  the  confusnig  nature 
of  the  presentation  from  so  many  ]>arts  being  felt  together,  there  is  the 
risk  of  the  hands  coming  down  and  converting  the  case  into  one  of  arm 
presentation,  fit  is  the  obvious  duty  of  the  accoucheur  to  prevent  this 
by  ensuring  the  descent  of  the  feet,  and  traction  should  be  made  on  them 
either  with  the  fingers  or  with  a  fillet,  until  their  descent  and  the  ascent 
of  the  hands  are  assured. 

Dorsal  Displacement  of  the  Arm. — In  connection  with  this  subject 
may  be  mentioned  the  curious  dorsal  displacement  of  the  arm  first 
described  by  Sir  James  Simpson,'  in  which  the  forearm  of  the  child 
becomes  thrown  across  and  behind  the  neck.  The  result  is  the  forma- 
tion of  a  ridge  or  bar  which  ])revents  the  descent  of  the  head  into  the 
pelvis  by  hitching  against  the  brim  (Fig.  121).  /The  difficulty  of  diag- 
nos'is  is  very  great,  for  the  cause  of  obstruction  ts  too  high  up  to  be  felt.) 
But  if  we  meet  with  a  case  in  which  the  ])elvis  is  roomy  and  the  jiains 
strong,  and  yet  the  head  does  not  descend  after  an  adc(|uatc  time,  a  full 
ex])1oration  of  the  cause  is  essential.  For  this  purpose  we  would  nat- 
urally put  the  patient  ujid^'_c[iloroforni  aji^  hand  sufficiently 
high.  We  might  then  feel  the  arm  in  its  abnormal  position.  That 
was  what  took  ])lacc  in  a  case  under  my  own  care  in  which  I  failed  to 
get  the  head  through  the  brim  with  the  forceps,  and  eventually  deliv- 
'  Selected  Obslet.  Worh,  vol.  i. 


PRESENTATIONS  OF  THE  SHOULDER,  ETC. 


337 


ered  by  turning.  The  same  course  was  adopted  by  my  friend  Mr.  Jar- 
dine  Murray  in  a  similar  case.^  (Simpson  advises  that  the  arm  should 
be  brought  down  so  as  to  convert  the  case  into  an  ordinary  hand-and- 
hcad  presentation^  This,  if  the  arm  be  above  the  brim,  must  always 
be  difficult,  and  I  believe  the  simpler  and  more  effective  plan  is  podalic 
version.  ^A  similar  displacement  may  cause  some  difficulty  in  breech 
presentations  and  after  turning  (Fig.  122).     Delay  here  is  easier  of 


Fig.  121, 


Fig.  122. 


Dorsal  Displacement  of  the  Arm. 


Dorsal  Displacement  of  the  Arm  in  Footling  Presen- 
tations.   (After  Barnes.) 


diagnosis,  since  the  obstacle  to  the  expulsion  will  at  once  lead  to  careful 
examination.  By  carrying  the  body  of  the  child  well  backward  so  as 
to  enable  the  finger  to  pass  behind  the  symphysis  pubis  and  over  the 
shoulder,  it  will  generally  be  easy  to  liberate  the  arm.^»' 

Prolapse  of  the  Umbilical  Cord. — It  occasionally  happens  that  the 
umbilical  cord  falls  down  past  the  presenting  part  (Fig.  123),  and  is  apt 
to  be  pressed  between  it  and  the  walls  of  the  pelvis.  The  consequence 
is  that  the  foetal  circulation  is  seriously  interfered  Avith,  and  the  death 
of  the  child  from  asphyxia  is  a  common  result.  Hence  prolapse  of  the 
funis  is  a  very  serious  complication  of  labor  in  so  far  as  the  child 
is  concerned. 

Frequency. — Fortunately,  it  is  not  a  very  frequent  occurrence. 
Churchill  calculates  that  out  of  over  105,000  deliveries  it  was  met  with. 

1  Med.  Times  and  Gazette,  1861. 
22 


338 


LABOR. 


once  in  240  eases,  ami  Seanzuni  once  in  254.  Its  frequency  varies  much 
under  ditterent  circumstances  and^m  different  places.  We  Hnd  from 
Churchill's  figures  a  remarkable  difference  in  the  proportional  number 
of  cases  observed  in  France,  England,  and  Germany — viz.  1  in  44Gi, 
1  in  207f,  and  1  in  156,  respectively.     Great  as  is  the  proportion  refer- 


FiG.  123. 


Prolapse  of  the  Umbilical  Cord. 


red  to  Germany  in  these  figures,  it  has  been  found  to  be  exceeded  in 
special  districts.  Thus,  Engelman  records  1  case  out  of  94  labors  in  the 
lying-in  hospital  at  Berlin,  and  Michaelis  1  in  90  in  that  of  Kiel. 
These  remarkable  differences  are  at  first  sight  not  easy  to  account  for. 
Dr.  Simpson  suggests,  with  considerable  show  of  probability,  that  the 
difference  in  frequency  in  England,  France,  and  Germany  may  depend 
on  the  varying  positions  in  which  lying-in  women  are  placed  during 
labor  in  each  country.  In  France,  Avhere,  although  the  patient  is  laid 
on  her  back,  the  pelvis  is  kept  elevated,  the  complication  occui"s  least 
frec^uently ;  in  England,  where  she  lies  on  her  side,  more  often  ;  and  in 
Germany,  where  she  is  placed  on  her  back  with  her  shoulders  raised, 
most  often.  The  special  frequency  of  prolapsed  funis  in  certain  dis- 
tricts, as  in  Kiel,  is  supposed  by  Engelman  ^  to  depend  on  the  preva- 
lence of  rickets,  and  consequently  of  deformed  pelvis,  which  we  shall 
presently  see  is  probably  one  of  the  most  frequent  and  important  causes 
of  the  accident- 
Prognosis. — With  regard  to  the  danger  attending  prolapsed  funis, 
^as  far  as  the  mother  is  concerned  it  may  be  said  to  be  altogether  unim- 
portant,]) butithe  universal  experience  of  obstetricians  points  to  the  great 
risk  to  which  the  child  is  subjected^  Scanzoni  calculates  that  45  per 
cent,  only  of  the  children  were  saved ;  Churchill  estimated  the  number 
at  47  per  cent.  ;  thus,  under  the  most  favorable  circumstances  thiscom- 

^Avier.  Journ.  of  Obst.,  1873-74,  vol.  vi.  pp.  409,  540. 


PRESENTATIONS  OF  THE  SHOULDER,  ETC.  339 

plication  leads  to  the  death  of  more  than  half  the  children.  Engelman 
found  that  out  of  202  vertex  ])i'eseiitall<>iis  <tiily  -I'j  ])er  cent,  of  the 
children  survived.  The  juurtality  was  not  nearly  so  great  in  other 
presentations ;  68  per  cent,  of  the  cases  in  which  the  child  presented 
with  tlie  feet  were  saved,  and  50  per  cent,  in  original  shoulder  presen- 
tations. \  The  reason  of  this  remarkable  difference  is  doubtless  that  in 
vertex  presentations  the  head  fits  the  pelvis  much  more  com})letely  and 
subjects  the  cord  to  much  greater  pressure  |  while  in  other  presentations 
the  pelvis  is  less  completely  filled,  and  the  interference  with  the  circu- 
lation in  the  cord  is  not  so  great.  Besides,  in  the  latter  case  the  com- 
plication is  detected  early  and  the  necessary  treatment  sooner  adopted. 

The  fcetal  mortality  is  considerably  greater  in  first  labors — a  result  to 
be  expected  on  account  of  the  greater  resistance  of  the  soft  parts  and 
the  consequent  prolongation  of  the  labor. 

The  causes  of  prolapse  of  the  funis  are  any  circumstances  which 
prevent  the  presenting  part  accurately  fitting  the  pelvic  brim.Y  Hence 
it  is  much  more  frequent  in  face,  breech,  or  shoulder  than  m  vertex 
presentations,  and  is  relatively  more  common  in  footling  and  shoulder 
presentations  than  in  any  other.  Amongst  occasional  accidental  predis- 
posing causes  may  be  mentioned  early  rupture  of  the  membranes, 
especially  if_the  amount  of  liquor  amnii  be  excessive,  as  the  sudden 
escape  of  the  fluid  washes  down  the  cord ;  undue  lenpi^th  of  the  cord 
itself;  or  an  unusually  low  placental  attach ment.  Engelman  attaches 
great  importance  to  slight  contraction  of  the  pelvis,  and  states  that  in 
the  Berlin  lying-in  hospital,  where  accurate  measurements  of  the  pelvis 
were  taken  in  all  cases,  it  was  almost  invariably  found  to  exist.  The 
explanation  is  evident,  since  one  of  the  first  results  of  pelvic  contrac- 
tion is  to  prevent  the  ready  engagement  of  the  presenting  part  in  the 
pelvic  brim. 

The  diag-nosis  of  cord  presentation  is  generally  devoid  of  difficulty; 
but  if  the  membranes  are  still  unruptured,  it  may  not  always  be  quite 
easy  to  determine  the  precise  nature  of  the  soft  structures  felt  through 
them,  as  they  recede  from  the  touch.  (  If  the  pulsations  of  the  cord  can 
be  felt  through  the  membranes,  all  difficulty  is  removedi  After  the  mem-y 
branes  are  ruptured  there  is  nothing  for  which  it  can  well  be  mistaken.' 

(The  important  point  to  determine  in  such  a  case  is  whether  the  cord 
be  pulsating  or  not;  for  if  pulsations  have  entirely  ceased  the  inference 
is  that  the  child  is  dead,  and  the  case  may  then  be  left  to  nature  with- 
out further  interference,  tli  is  of  importance,  however,  to  be  careful, 
for  if  the  examination  be  made  during  a  pain  the  circulation  might  be 
only  temporarily  arrested.  The  examination,  therefore,  should  be  made 
during  an  interval,  and  a  loop  of  the  cord  pulled  down,  if  necessary,  to 
make  ourselves  absolutely  certain  on  this  point. 

The  amount  of  the  Drolai3se  varies  much.  Sometimes  only  a  knuckle 
of  the  cord,  so  small  as  to  escape  observation,  is  engaged  between  tlie 
pelvis  and  presenting  part.  Under  such  circumstances  the  child  may 
be  sacrificed  without  any  suspicion  of  danger  having  arisen.  More 
often  the  amount  prolapsed  is  considerable — sometimes  so  as  to  lie  in  the 
vagina  in  a  long  loop,  or  even  to  protrude  altogether  beyond  the  vulva. 

In  the  treatment  the  great  indication  is  to  prevent  the  cord  from 


340 


LABOR. 


( 


bcinp:  uiululv  prc?isecl  on,  and  all  our  endeavors  must  liave  this  oV)joot 
in  view.  it'  the  presentation  he  detected  before  the  full  dilatation 
of  the  cervix,  and  Mhen  the  membranes  are  nnruj)tured,  we  must  try 
to  keep  the  cord  out  of  the  way;  to  preserve  the  membranes  intact  as 
long  as  poasible,  since  the  cord  is  tolerably  protected  as  long  as  it  is  sur- 
rounded by  the  liquor  amnii^  and  to  secure  the  complete  dilatation  of 
the  OS,  so  that  the  presenting  part  may  engage  rapidly  and  completely. 

Much  may  be  done  at  this  time  by  the  postural  treatment,  which  we 
owe  chiefly  to  the  ingenuity  of  Dr.  T.  Gaillard  Thomas  of  New  York, 
whose  writings  familiarized  the  profession  witli  it,  although  it  apjK'ai-s 
that  a  somewhat  similar  i)lan  had  been  occasionally  adoj^ted  previously. 
Dr.  Thomas'  method  is  based  on  the  principle  of  causing  the  cord  to 
slip  back  into  the  uterine  cavity  by  its  own  -weight. )  For  this  purjiose 
the  patient  is  placed  oirTieFliaiTds^aliH'^ee^  with  the  hips  elevated  and 
the  shoulders  resting  on  a  lower  level  (Fig.  124).     The  cervix  is  then 

Fig.  124. 


Postural  Treatment  of  Prolapse  of  the  Cord. 

no  longer  the  most  dependent  portion  of  the  uterus,  and  the  anterior 
wall  of  the  uterus  forms  an  inclined  plane  down  which  the  cord  slips. 
'The  success  of  this  manoeuvre  is  sometimes  very  great,  but  by  no  means 
always  so)  (It  is  most  likely  to  succeed  when  the  membranes  are  un- 
ruptured. }  If,  when  adopted,  the  cord  slip  away  and  the  os  be  suffi- 
ciently dilated,  the  membranes  may  be  rujitured,  and  engagement  of  the 
head  produced  by  properly  aj^plied  uterine  j^ressure.  Sometimes  the 
position  is  so  irksome  that  it  is  impossible  to  resort  to  it.  Postural 
treatment  is  not  even  then  altogether  impossible,  for  by  placing  the 
patient  on  the  side  opposite  to  that  of  the  prolapse,  so  as  to  relieve 
the  cord  as  much  as  possible  from  pressure,  and  at  the  same  time 
elevating  the  hips  by  a  pillow,  it  may  slip  back.  /Even  after  the 
membranes  are  ruptured  postural  treatment  in  one  form  or  another 
may  succeed  ;  and,  as  it  is  simple  and  Iiarmlcss,  it  should  ccrtaiidy 
be  always  tried.^  Attempts  at  reposition  by  one  or  other  of  the 
methods  described  below  may  also  occasionally  be  facilitated  by  try- 
ing them  w'hen  the  patient  is  placed  in  the  knee-shoulder  jiosition. 
Failing  by  postural  treatment  or  in  combination  with  it,  it  is  quite 


PRESENTATIONS  OF  THE  SHOULDER,  ETC. 


341 


legitimate  to  make  an  attempt  to  place  the  cord  beyond  the  reach  of 
dangerous  pressure  by  other  methods.  Unfortunately,  i-eposition  is  too 
often  disappointing,  difficult  to  effect,  and  very  frequently,  even  when 
apparently  successful,  shortly  followed  by  a  fresh  descent  of  the  cord. 
/Provided  the  os  be  fully  dilated  and  the  presenting  head  engaged  in  the 
pelvis  (for  reposition  may  be  said  to  be  hopeless  when  any  other  part 
presents),  perhaps  the  best  way  is  to  attempt  it  b^Jii^J^miicLalone. 
Probably  the  simplest  and  most  effectual  method  is  that  recommended^ 
by  McClintock  and  Hardy,  who  advise  that  the  patient  should  lie 
on  the  opposite  side  to  the  prolapsed  cord,  which  should  then  be 
drawn  toward  the  pubes  as  being  the  shallowest  part  of  the  pelvis. 
Two  or  three  fingers  may  then  be  used  to  push  the  cord  past  the 
head  and  as  high  as  they  can  reach.  They  must  be  kept  in  the 
pelvis  nntil  a  pain  comes  on,  and  then  very  gently  withdrawn,  in  the 
hope  that  the  cord  may  not  again  prolapse.  During  the  pain  ex- 
ternal pressure  may  very  properly  be  applied  to  favor  descent  of  the 
head.  This  manoeuvre  may  be  repeated  during  several  successive 
pains,  and  may  eventually  succeed.  The  attempt  to  hook  the  cord 
over  the  foetal  limbs  or  to  place  it  in  the  hollow  of  the  neck,  recom- 
mended in  many  works,  involves  so  deep  an  introduction  of  the  hand 
that  it  is  obviously  impracticable. 

Various  coniplex  instruments  have  been  invented 
to  aid  reposition  (Fig.  125),  but  even  if  we  possessed 
them  they  are  not  likely  to  be  at  hand  when  the 
emergency  arises.  A  simple  instrument  may  be 
improvised  out  of  an  ordinary  male  elastic  catheter 
by  passing  the  two  ends  of  a  piece  of  string  through 
it,  so  as  to  leave  a  loop  emerging  from  the  eye  of 
the  catheter.  This  is  passed  through  the  loop  of 
prolapsed  cord,  and  then  fixed  in  the  eye  of  the 
catheter  by  means  of  the  stilette.  The  cord  is  then 
pushed  up  into  the  uterine  cavity  by  the  catheter,  and 
liberated  by  withdrawing  the  stilette.  Another  sim- 
ple instrument  may  be  made  by  cutting  a  hole  in  a 
piece  of  whalebone.  A  piece  of  tape  is  then  passed 
through  the  loop  of  the  cord  and  the  ends  threaded 
through  the  eye  cut  in  the  whalebone.  By  tighten- 
ing the  tape  the  whalebone  is  held  in  close  apposi- 
tion to  the  cord,  and  the  whole  is  passed  as  high 
as  possible  into  the  uterine  cavity.  The  tape  can 
easily  be  liberated  by  pulling  one  end.  If  pre- 
ferred, the  cord  can  be  tied  to  the  whalebone, 
which  is  left  in  utero  until  the  child  is  born. 
Nothing  need  be  said  as  to  the  various  other 
methods  adopted  for  keeping  up  the  cord,  such  as 
the  insertion  of  pieces  of  sponge  or  tying  the  cord 
in  a  baa:  of  soft  leather,  since  they  are  generally  ad- 

•i-i.    1    J.      u  -i.  1  ./  o  ^  Braun's  Apparatns  for 

mitted    to    be    quite    useless.  Replacing  the  Cord. 

It  only  too  often  happens  that  all  endeavors  at 
reposition  fiiil.     The  subsequent  treatment  must  then  be  guided  by  the 


342  LABOR. 

ciivunistanocf;  ol"  the  case,  (If  the  pelvis  he  roomv  Jiiul  the  })aiii.s  .strong, 
especially  in  a  multipara,  we  may  often  deem  it  advisable  to  leave  the 
case  to  natiu'e,  in  the  hope  that  the  head  may  be  pushed  throiitrh  before 
pressure  on  the  cortl  has  had  time  to  ])rove  fatal  to  the  child.-^  Under 
such  circunistances  the  ])atient  should  be  urj^ed  to  bear  down,  and  the 
descent  of  the  head  promoted  by  uterine  j)ressure,  so  as  to  get  the 
second  stage  completed  as  soon  as  possible.  If  the  head  be  within  easy 
reach,  the  application  of  the  forceps  is  quite  justifiable,  since  delay  must 
necessarily  involve  the  death  of  the  child.  During  this  time  the  cord 
should  be  placetl,  if  possible,  opposite  one  or  other  sacro-iliac  synchon- 
drosis, according  to  the  position  of  the  head,  as  the  ])art  of  the  ])elvis 
where  there  is  most  room  and  where  the  pressure  would  consequently  be 
least  prejudicial.  If  we  have  to  do  Mith  a  case  in  which  the  head  has 
not  descended  into  the  pelvis,  and  ])ostural  treatment  and  reposition  have 
both  failed,  provided  the  os  be  fully  dilated  and  other  circumstances  be 
favorable,  turning  would  undoubtedly  oifer  the  l)est  chance  to  the  child. 
This  treatment  is  strongly  advocated  by  Engelman,  who  found  that  70 
per  cent,  of  the  children  delivered  in  this  way  were  saved.  There  can 
be  no  question  that,  so  far  as  the  interests  of  the  child  are  concerned,  it 
is,  under  the  circumstances  indicated,  by  far  the  best  expedient.  Turn- 
ing, however,  is  by  no  means  always  devoid  of  a  certain  risk  to  the 
mother,  and  the  performance  of  the  operation  in  any  ])articular  case 
must  be  left  to  the  judgment  of  the  practitioner.  A  fully-dilated  os 
with  membranes  unruptured,  so  that  version  could  be  })('rformed  by  the 
combined  method  without  the  introduction  of  the  hand  into  the  uterus, 
would  be  unquestionably  the  most  favorable  state.  If  it  be  not  deemed 
proper  to  resort  to  it,  all  that  can  be  done  is  to  endeavor  to  save  the  cord 
from  pressure  as  much  as  possible  by  one  or  other  of  the  methods  already 
mentioned. 


CHAPTER   IX. 
PROLONGED   AND   PRECIPITATE   LABORS. 

Amoxo  the  difficulties  connected  with  parturition  there  are  none  of 
more  frequent  occurrence,  and  none  rcfjuiring  more  thorough  knowledge 
of  the  physiology  and  ])atliology  of  labor,  than  those  arising  from  defi- 
cient or  irregular  action  of  the  expulsive  powers.  The  importance  of 
studying  this  class  of  labors  will  be  seen  when  we  consider  the  numerous 
and  very  diverse  causes  which  produce  them. 

Evil  Effects  of  Prolonged  Labor.-(-That  the  mere  prolongation  of 
labor  is  in  itself  a  serious  thing  is  bccominj^  daily  more  and  more  an 
acknowledged  axiom  of  midwifery  practice^  and  that  this  is  so  is  evi- 
dent when  we  contrast  the  statistical  returns  of  such  institutions  as  the 


PROLONGED  AND  PRECIPITATE  LABORS.  343 

Rotunda  Lying-in  Hospital  of  late  years  with  those  which  were  pul> 
lishcd  some  twenty  or  thirty  years  ago.  It  may  he  fairly  assumed  that 
the  })raetice  of  the  distinguished  heads  of  that  well-known  school  rep- 
resents the  most  advanced  and  scientific  opinion  of  the  day.  When  we 
find  that  less  than  thirty  years  ago  tlie  forceps  was  not  used  more  than 
once  in  310  labors,  while,  according  to  the  report  for  1873,  the  late 
master  ap])lied  it  once  in  8  labors,  it  is  apparent  how  great  is  the 
change  which  lias  taken  place. 

Causes. — Labor  may  be  prolonged  from  an  immense  number  of 
causes,  the  principal  of  which  will  require  separate  study.  Some  depend 
simply  on  defective  or  irregular  action  of  tlie  uterus  -others  act  by 
opposing  the  expulsion  of  the  child,  as,  foFexampTe,  undue  rigidity  of 
the-pai'turient  passages,  tumors,  bony  deformity,  and_tliejike.  What- 
ever the  source  of  delay,  a  train  of  formidable  symptoms  is  developed 
which  are  fraught  with  peril  both  to  the  mother  and  the  child.  As 
regards  the  mother,  they  vary  much  in  degree  and  in  the  rapidity  with 
which  they  become  established.  In  many  cases,  in  which  the  action  of 
the  uterus  is  slight,  it  may  be  long  before  serious  results  follow  ;  while 
in  others,  in  which  a  strongly-acting  organ  is  exhausting  itself  in  futile 
endeavors  to  overcome  an  obstacle  the  worst  signs  of  protraction  may 
come  on  with  comparative  rapidity. 

The  stage  of  labor  in  which  delay  occurs  has  a  marked  effect  in 
the  production  of  untoward  symptoms.  ■  It  is  a  well-established  fact 
that  prolongation  is  of  coniparatively  small  conse(][uence  to  either  the 
mother  or  child  in  the  first  stage,  when  the  membranes  are  still  intact 
and  when  the  soft  parts  of  the  mother,  as  well  as  the  body  of  the  child, 
are  protected  by  the  liquor  amnii  from  injurious  pressure^  whereas 
if  the  membranes  have  ruptured  prolongation  becomes  of  the  utmost 
importance  to  both  as  soon  as  the  head  has  entered  the  pelvis,  when  the 
uterus  is  strongly  excited  by  reflex  stimulation,  when  the  maternal  soft 
parts  are  exposed  to  continuous  pressure,  and  when  the  tightly  con- 
tracted uterus  presses  firmly  on  the  foetus  and  obstructs  the  placental 
circulation.  It  is  in  reference  to  the  latter  class  of  cases  that  the  change 
of  practice,  already  alluded  to,  has  taken  place,  with  the  utmost  bene- 
ficial results  both   to  mother  and  child. 

It  must  not  be  assumed,  however,  that  prolongation  of  labor  is  never 
of  any  consequence  until  the  second  stage  has  commenced. )  The  fallacy 
of  such  an  opinion  was  long  ago  shown  by  Simpson,  who  proved  in  the 
most  conclusive  way  that  both  the  maternal  and  foetal  mortality  were 
greatly  increased  in  proportion  to  the  entire  length  of  the  labor ;  and  all 
practical  accoucheurs  are  familiar  with  cases  in  M'hich  symptoms  of 
gravity  have  arisen  before  the  first  stage  is  concluded.  Still,  relatively 
speaking,  the  opinion  indicated  is  undoubtedly  correct. 

In  the  present  chapter  we  liave  to  do  only  M'ith  those  causes  of  delay 
connected  with  the  expulsive  powers.  Inasmuch,  however,  as  the  inju- 
rious effects  of  protraction  are  similar  in  kind,  whatever  be  the  cause,  it 
will  save  needless  repetition  if  we  consider,  once  for  all,  the  train  of 
symptoms  that  arise  whenever  labor  is  unduly  prolonged. 

Delay  in  the  First  Stage  is  Rarely  Serious. — As  long  as  the  delay 
is  in  the  first  stage  only,  with  rare  exceptions  no  symptoms  of  real  grav- 


344  LABOR. 

ity  arise  for  a  lon<2;tli  of  time,  it  iiiav  be  even  for  days.  There  is  ofteu, 
however,  a  partial  cessation  of  the  pains,  which  in  consequence  of  tem- 
porary exhaustion  of  nervous  force  may  even  entirely  disa])]K'ar  for 
many  consecutive  hours.  ^Under  such  circumstances,  after  a  perifMJ  of 
rest  either  natural  or  j>roduced  by  suitable  sedatives,  they  recur  with 
renewed   vi^or.  ^ 

Symptoms  of  Protraction  in  the  Second  Stage. — A  similai-  tem- 
])orary  cessation  of  the  pains  may  often  be  observed  after  the  hciul  has 
]):Ls.sed  through  the  os  uteri,  to  be  also  followed  by  renewed  vigorous 
action  after  rest.  But  now  any  such  irregularity  nuist  be  nuich  more 
anxiously  watched.  In  the  majority  of  cases  any  marked  alteration  in 
the  force  and  frequency  of  the  jwins  at  this  period  indicates  a  much 
more  serious  form  of  delay,  which  in  no  long  time  is  acc(tmpanied  by 
grave  general  symptoms.  The  pulse  begins  to  rise,  the  skin  to  become 
hot  and  dry,  the  ])aticnt  to  be  restless  and  irritaljle.  The  longer  the 
delay  and  the  more  violent  the  efforts  of  the  uterus  to  overcome  the 
obstacle,  the  more  serious  docs  the  state  of  the  patient  l)ecome.  The 
tongue  2*  loaded  with  fur,  and  in  the  worse  cases  dry  and  black  ;  nausea 
ana  vomiting  often  become  marked7~tTie  vagina  feels  hot  and  dry,  the 
ordinary  abundant  miicous  secretion  being  al)sent ;  in  severe  cases  it  may 
be  much  s}yollen,  and  if  the  presenting  part  be  firmly  impacted  a  slough 
may  even  form.  CShould  the  patient  still  remain  undelivered,  all  these 
symptoms  become  greatly  intensified:  the  vomiting  is  incessant,  the 
pulse  is  rapid  and  almost  imperceptible,  low  nmttering  delirium  super- 
venes^ and  the  patient  eventually  dies  with  all  the  worst  indications  of 
profound  irritation  and  exhaustion.^ 

So  formidable  a  train  of  symptoms,  or  even  the  slighter  degrees  of 
them,  should  never  occur  in  the  practice  of  the  skilled  obstetrician  ;  and 
it  is  precisely  because  a  more  scientific  knowledge  of  the  process  of  par- 
turition has  taught  the  lesson  that  under  such  circumstances  ])revention 
is  better  than  cure,  that  earher  interference  has  become  so  much  more 
the  rule. 

Those  who  taught  that  nothing  should  be  done  until  nature  had  had 
every  possible  chance  of  effecting  delivery,  and  mIio,  therefore,  allowed 
their  patients  to  drag  on  in  many  weary  hours  of  labor  at  the  ex])ense 
of  great  exhaustion  to  themselves  and  imminent  risk  to  their  ofi'sjtring, 
made  much  capital  out  of  the  time-honored  maxim  that  "  mctldlesome 
mid\yifery  is  bad."  AVhen  this  proverb  is  applied  to  restrain  the  rash 
interference  of  the  ignorant,  it  is  of  undeniable  value  ;  but  when  it  is 
quoted  to  jn-event  tlie  scientific  action  of  the  experienced,  who  know 
])reciscly  when  and  why  to  interfere,  and  who  have  acquired  the 
indispensable  mechanical  skill,  it  is  sadly   misn])j>lied. 

State  of  the  Uterus  in  Protracted  Labor. — The  nature  of  the 
])ains  and  the  state  of  the  uterus  in  ca-scs  of  j)rotractcd  labor  are  pecu- 
liarly worthy  of  study,  and  have  been  verj'  clearly  pointed  out  by  Dr. 
Braxton  Hicks.*  (  He  sho\ys  that,  when  the  jiains  have  apparently 
fallen  off  and  become  fe^v  and  feeble,  or  have  entirely  ceased,  the  uterus 
is  in  a  state  of  continuous  or  tome  contraction,  and  that  the  irritation 
resuhing  from  this  is  the  chief  cause  of  tlie  more  marked  symptoms  of 

'  Obst.  Trans.,  1867,  vol.  ix.  p.  207. 


PROLONGED  AND  PRECIPITATE  LABORS.  345 

powerless  labor.     If  in  a  case  of  the  kind  the  uterus  be  examined  by  \ 
palpation,  it  will  be  foinid  firmly  contracted  between  the  j)ains.     Tiie  i 
correctness  of  this  observation  is  beyond  question,  and  it  will  no  doubt  ' 
often  be  an  important  guide  in  treatment.     Under  such  circumstances 
instrumental  interference  is  imperatively  demanded. 

Causes. — In  considering  the  causes  of  protracted  labor  it  will  be 
well  first  to  discuss  those  which  aifect  the  expulsive  powers  alone,  leav- 
ing those  depending  on  morbid  states  of  the  passages  for  future  consid- 
eration ;  bearing  in  mind,  however,  that  the  results  as  regards  both  the 
mother  and  the  cliild  are  identical  whatever  may  be  the  cause  of  delay. 

The  general  constitutional  state  of  the  patient  may  materially  influ-  ' 
ence  the  force  and  efficiency  of  the  pains.  Thus  it  not  unfrequeutly 
happens  that  they  are  feeble  and  ineffective  in  women  of  very  weak  con- 
stitution or  who  are  much  exhausted  by  debilitating  disease.  Cazeaux 
pointed  out  that  the  effects  of  such  general  conditions  are  often  more 
tlian  counterbalanced  by  flaccid  ity  and  want  of  resistance  of  the  tissues, 
so  that  there  is  less  obstacle  to  the  passage  of  the  child.  Thus  in  phthisi- 
cal patients  reduced  to  the  last  stage  of  exhaustion  labor  is  not  unfre- 
queutly surj)risingly  easy. 

Lfl-Ug  residence  in  tropical  climates  causes  uterine  inertia,  in  conse-  i^ 
quence  of  the  enfeebled  nervous  power  it  produces.  It  is  a  common 
observation  that  European  residents  in  India  (ai'e  peculiarly  apt  to 
suffer  from  post-partum  hemorrhage  from  this  cause.^  The  general 
made  of  hfe  of  patients  has  an  unquestionable  effect ;  and  it  is  certain 
that  deficient  and  irregular  uterine  action  is  more  common  in  women 
of  the  higher  ranks  of  society,  who  lead  luxurious,  enervating  lives, 
than  in  women  Avhose  habits  are  of  a  more  healthy  character. 

Tyler  Smith  lays  much  stress  on  frecpient  cliildbeariug  as  a  cau-e  of  '  ' 
inei-tia,  pointing  out  that  a  uterus  which  has  been  very  frequently  sub- 
jected to  the  changes  connected  with  pregnancy  is  unlikely  to  be  in  a 
typically  normal  condition.  [  It  is  doubtful,  however,  whether  the 
uterus  of  a  perfectly  healthy  woman  is  affected  in  this  way )  certainly, 
if  childbearing  had  undermined  her  general  health,  the  labors  are  likely 
to  be  modified  also.  , 

Age  has  a  decided  effect.  (  In  the  very  young  the  pains  are  apt  to  be 
irregular,  oii'account  of  imperfect  development  of  the  uterine  muscle.) 
/Labor  taking  place  for  the  first  time  in  women  advanced  in  life  is  also 
apt  to  be  tedious)  but  not  by  any  means  so  invariably  as  is  generally 
believed.  The  apprehensions  of  such  patients  are  often  agreeably 
falsified,  and  where  delay  does  occur  it  is  probably  more  often  refer- 
able to  rigidity  and  toughne&s  of  the  parturient  passages  than  to  feeble- 
ness of  the  pains.  . 

Morbid  st;vtes_of_tlie  prinife  vioe  frequently  cause  irregular,  painful,  v^ 
and  feel)le  contractions.  A  loaded  state  of  thel'ectum  has  a  remark- 
ame~TnHuen"ce,  as  evidenced  l)y  the  sudden  and  distinct  change  in  the 
character  of  the  labor  Avhich  often  follows  the  use  of  suitable  remedies. 
Undue  distension  of  the  bladder  may  act  in  the  same  way,  more  espe- 
cially in  the  second  stage.  When  the  urine  has  been  allowed  to  accu- 
mulate unduly,  the  contraction  of  the  accessory  muscles  of  jiarturition 
often  causes  such  intense  suffering,  by  compressing  the  distended  viscus, 


;}4G  LABOR. 

tliMt  till'  jmtient  is  al)S(»liit('ly  iiiuiblc  lo  bear  down.  IIciicc  tlic  lalxtr  is 
(•allied  on  by  uterine  eonliactions  alone,  slowly  and  at  the  expense  of 
iniieh  suil'erinjr.  A  similar  inteiierence  with  the  action  of  tlie  accessory 
muscles  is  often  jnoduced  by  other  causes.  [We  sometimes  meet  Avitli 
what  may  be  desitriiated  as  reenrrent  uterine  fati{:;ue,  in  which  the  first 
stage  of  lal)or  ])ro<;resses  slowly,  with  intervals  ol'  entire  suspension  of 
uterine  action,  when  the  organ  W(»uld  appeal"  to  l)e  taking  a  rest.  This 
peculiar  irregularity  may  be  ibund  where  the  patient  is  in  a  fair  degree 
of  health  and  lias  not  been  enfeebled  by  any  recognizable  c-ause.  In 
one  very  marked  instance  under  my  care  in  the  higher  walks  of  life 
labor  came  on  at  night,  ceased  in  the  morning,  and  was  susj)eiided  for 
the  day,  the  patient  being  up  and  about ;  on  the  second  night  labor  was 
renewed,  to  be  followed  by  a  second  day  of  cessation.  The  third  night 
I  went  to  bed  in  the  house,  antici])ating  the  possibility  (»f  a  rapid  second 
stage,  in  wdiich  I  was  not  disaj)pointed.  As  might  also  be  looked  for 
in  such  a  case,  there  was  a  recurrence  of  uterine  inertia  an  hour  after 
the  placenta  came  away,  and  a  disposition  to  hemorrhage  lasting  for 
six  hours.  The  child  born  was  the  third,  and  in  the  fourth  labor 
there  Mas  no  trouble  of  any  kind. — Ed.]  Thus  if  labor  comes  on 
when  the  patient  is  suffering  from  bronchitis  or  other  clu'st  disease  she 
may  be  r^uite  unable  to  fix  tlie  chest  by  a  deep  in.spiration,  and  the  dia- 
phragm and  other  accessory  muscles  cannot  act.  In  the  same  way  they 
may  be  prevented  from  acting  when  the  abdomen  is  occupied  by  an 
ovarian  tumor  or  by  ascitic  fluid. 

^Mental  conditions  have  a  very  marked  effect.  This  is  so  commonly 
'  observetl  that  it  is  familiar  to  the  incrost  beginner  in  midwifery  prac- 
tice. The  fact  that  the  pains  often  diminish  temporarily  on  the  entrance 
of  the  accoucheur  is  known  to  every  nurse;  and  so  also  undue  excite- 
ment, the  presence  of  too  many  peo])le  in  the  room,  overmuch  talking, 
have  often  the  same  prejudicial  effect.  Depression  of  mind,  as  in 
unmarried  women,  and  fear  and  despondency  in  women  who  have 
looked  forward  with  ap])rehcnsion  to  the  labor,  are  also  common 
causes  of  irregular  and  defective  action. 
t/  Undue  distension  of  the  uterus  from  an  excessive  amount  of  liquor 
0  aQUiji  not  unfrequeutly  retards  the  first  stage,  I)y  preventing  the  uterus 
from  contracting  efficiently.  When  this  exists,  the  jiains  are  feeble  and 
have  little  effect  in  dilating  the  cervix  bevond  a  certain  degree.  This 
cause  may  be  suspected  Avhen  undue  jji'otraetion  of  the  first  stage  is 
associated  with  an  unusually  large  size  and  marked  fluctuation  of  the 
uterine  tumor,  through  which  the  foetal  limbs  cannot  be  made  out  on 
palpation.  On  vaginal  examination  the  lower  segment  of  the  uterus 
will  be  found  to  be  very  rounded  and  prominent,  while  the  bag  of 
membranes  will  not  bulge  through  the  os  during  the  acme  of  the 
pain. 

A  somewhat  similar  cause  is  undue  obliquity  of  the  uterus,  which 
prevents  the  pains  acting  to  the  best  mechanical  advantage,  and  often 
retards  the  entry  of  the  presenting  part  into  the  brim.  The  most  com- 
mon variety  is  ajitcversion^resultini:  from  undue  laxity  of  the  abdomi- 
nal parietes,  which  is  especially  found  in  women  who  liave  borne  many 
children.     Sometimes  that  is  so  exces.sive  that  the  fundus  lies  over  the 


PROLONGED  AND  PRECIPITATE  LABORS.  347 

pubes,  and  even  projects  downward  toward  the  patient's  knees.  Tlie 
consequence  is,  tliat  when  labor  sets  in,  unless  corrective  means  be  taken, 
the  pains  force  the  liead  against  the  sacrum,  instead  of  directing  it  into 
the  axis  of  the  pelvic  inlet.  Another  common  deviation  is  lateral 
oI)liquity,  a  certain  degree  of  which  exists  in  almost  all  cases',"  but 
sometimes  it  occurs  to  an  excessive  degree.  Either  of  these  states 
can  readily  be  detected  by  palpation  and  vaginal  examination  com- 
bined. In  the  former  the  os  may  be  so  high  up  and  tilted  so  far  back- 
ward that  it  may  be  at  first  difficult  to  reach  it  at  all. 

Irregular  and  Spasmodic  Pains.— ^Besides  being  feel)]e,  the  uterine 
contractions,  especially  in  the  first  stage,  are  often  irregular  and  spas- 
modic, intensely  painful,  but  producing  little  or  no  effect  on  the  prog- 
ress of  the  labor.)  This  kind  of  case  has  been  already  alluded  to  in 
treating  of  the  use  of  ausesthetics  (p.  299),  and  is  very  common  in 
highly  nervous  and  emotional  women  of  the  upper  classes.  In  such 
cases  cocaine  has  been  of  late  used  as  a  local  application  with  decided 
benefit.  It  appears  to  act  by  deadening  the  pain  resulting  from  the 
stretch ino;  of  the  nerves  of  the  cervix  or  from  slight  cervical  lacera- 
tions.  It  has  no  effect  in  relieving  the  suffering  caused  by  uterine 
contraction.^  It  has  been  applied  by  means  of  a  cotton-wool  tampon 
steeped  in  a  2  per  cent,  solution  and  placed  against  the  os.  A 
much  better  way  of  using  it  is  by  "  Moore's  cones,"  ^  made  with 
cacoa  butter,  one  of  which  is  placed  on  the  examining  finger  like  a 
thimble  and  inserted  within  the  os,  where  it  rapidly  melts.  Such 
irregular  contractions  do  not  necessarily  depend  on  mental  causes 
alone,  and  they  often  follow  conditions  producing  irritation,  such  as 
loaded  bowels,  too  early  rupture  of  the  membranes,  and  the  like.  Dr. 
Trenholme  of  ]MoutreaP  believes  that  such  irregular  pains  most  fre- 
quently depend  on  abnormal  adhesions  bet^s'een  the  decidua  aud  the 
uterine  walls,  which  interfere  with  the  proper  dilatation  of  the  os,  and 
he  has  related  some  interesting  cases  in  support  of  this  theory. 

Treatment. — The  mere  enumeration  of  these  various  causes  of  pro- 
tracted labor  will  indicate  the  treatment  required.  (Some  of  them,  such 
as  the  constitutional  state  of  the  patient,  age,  or  mental  emotion,  it  is 
of  course  beyond  the  power  of  the  practitioner  to  influence  or  modify ;) 
but  in  every  case  of  feeble  or  irregular  uterine  action  a  careful  investi- 
gation should  be  made  M-ith  the  view  of  seeing  if  any  removable  cause 
exist.  For  example/the  effect  of  a  large  enema  when  we  suspect  the 
existence  of  a  loaded  rectum  is  often  very  remarkable,) the  pains  fre- 
quently almost  immediately  changing  in  character,  and  a  previously 
lingering  labor  being  rapidly  terminated. 

(Excessive  distension  of  the  uterus  can  only  be  treated  by  artificial 
evacuation  of  the  liquor  amnii  ;\and  after  this  is  done  the  characTer  of 
the  pains  often  rapidly  changes.  This  expedient  is  indeed  often  of  con- 
siderable value  in  cases  in  which  the  cervix  has  dilated  to  a  certain 
extent,  but  in  which  no  further  progress  is  made,  esjiecially  if  the  bag 
of  membranes  does  not  protrude  through  the  os  during  the  pains,  and 

^  "  The  Value  of  Cocaine  in  Obstetrics,"  by  John  Phillips,  B.  A.,  M.  D.,  Lancet, 
November  26,  1887. 

^Brit.  Med  Journ.,  1885,  vol.  ii.  p.  1140.  =  Obst.  Trans.,  1873,  vol.  xiv.  p.  231. 


348  LABOR. 

thf  cervix  it.^oir  is  soft  and  appaiviitly  readily  (lilatable.  Under  .-iieh 
circinustances  rupture  of  the  meuibraues,  even  l)efore  the  os  fully  dilate<l, 
is  often  very  useful. 

il^  Ave  have  reason  to  suspect  morbid  adhesions  between  the  nicni- 
branes  and  the  uterine  walls,  an  endeavor  must  be  made  to  sej)arate 
them  bv  sweeping  the  finger  or  a  flexible  Ciitheter  round  the  internal 
margin  of  the  os  or  puncturing  the  sac.  Y  The  former  expedient  has 
been  advocated  by  Dr.  luglis '  as  a  means  of  increasing  the  pains  when 
the  first  stage  is  very  tedious,  and  I  have  often  itraetised  it  with  marked 
success.  Trenholme's  observation  affords  a  rationale  of  its  action.  The 
manoeuvre  itself  is  easily  acconii)lish('d,  and,  ]»rovidcd  the  os  be  not  very 
hit^h  in  the  pelvis,  does  not  give  any  pain  or  discomfort  to  the  patient. 

(Attention  should  always  be  paid  to  remedying  any  deviations  of  the 
uterus  from  its  proi)er  axis.)  If  this  be  lateral,  the  proper  course  to 
pui-sue  is  to  make  the  patient  lie  on  the  opposite  side  to  that  toward 
which  the  organ  is  pointing.)  In  the  more  common  anterior  deviation 
she  should  lie  on  her  back,  so  that  the  uterus  may  gravitate  toward  the 
spine,  and  aJimj_abdominal  bandage  should  be  aj)j)lied.  This  jirevents 
the  organ  from  falling  forward,  wTiile  its  pressure  stimulates  the  mus- 
cular fibres  to  increased  action  ;  hence  it  is  often  very  serviceable  when 
the  pains  are  feeble,  even  if  there  be  no  antevei*sion. 

(  In  a  frequent  class  of  cases,  especially  in  the  first  stage,  the  pains 
diminish  in  force  and  frequency  fi'om  fatigue,  and  the  indication  then  is 
to  giye  a  temporary_rest,  after  which  they  recommence  with  renewed 
vigor.^  Hence  an  opjatj,  such  as  20  minims  of  Battley's  solution,  which 
often  acts  quickest  when  given  in  the  form  of  enema,  is  frequently  of  the 
greatest  possible  value.  If  this  secure  a  few  hours'  sleep,  the  patient 
will  generally  awake  much  refreshed  and  invigorated.  It  is  important 
to  distinguish  this  variety  of  arrested  pain  from  that  de]iendent  on  actual 
exhaustion  ;  and  this  can  be  done  by  attention  to  the  general  condition 
of  the  patient,  and  especially  by  observing  that  the  uterus  is  soft  and 
flaccid  in  the  intervals  between  the  pains,  and  that  there  is  none  of  the 
tonic  contraction  indicated  l)y  persistent  hardness  of  the  uterine  parietes. 
AVhen  the  pains  are  irregular,  spasmodic,  and  excessively  painful,  with- 
out producing  any  real  effect,  opiates  are  also  of  great  service;  and  it  is 
under  such  circumstances  that  chloral  is  especially  valuable. 

Oxytocic  Remedies. — Still,  a  large  number  of  cases  will  arise  in 
which  the  absence  of  all  removable  causes  has  l)een  ascertained,  and  in 
which  the  pains  are  feeble  and  ineffective.  We  must  now  proceed  to 
discuss  their  management.  The  fault  being  the  want  of  sufficient  con- 
traction, the  first  indication  is  to  increase  the  force  of  the  pains.  Here 
the  so-called  o.^-|//or/r  remedies  come  into  action;  and,  although  a  large 
number  of  these  have  been  used  from  time  to  time,  such  as  Iwax,  ciupa- 
mon,  quinine,  and  galvanism,  practically  the  (»nly  one  in  which  reliance 
is  generally  jilaced  is  the  ergot  of  rve.  This  has  long  been  the  favorite 
remedy  for  deficient  uteri iITrnrTtnTTTTfnd  it  is  a  jiowerful  stinndant  of  the 
uterine  fibres.  It  has,  however,  very  serious  disadvantages,  and  (it  is. 
veiy  questionable  whether  the  risks  to  both  mother  and  child  do  not 
more   than   counterbalance  any  advantages  attending   its   use.y     The 

'  Sydenham  Society's  Year-Book,  1867,  p.  399. 


PROLONGED  AND  PRECIPITATE  LABORS.  349 

(ergot  is  giveu  in  doses  of  15  or  20  grains] of  the  freslily- powdered 
drug  iinf used  in  warm  water,  or  in  the  more  convenient  form  of  the 
^iquid  extract  in  doses  of  from  20  to  30  minims,  )or,  still  better,  in 
the  form  of  er^otine  injected  hv])odermically,  3  to  4  minims  of  the 
hypodermic  solution  being  used  for  the  purpose.  In  about  fifteen ' 
minutes  after  its  administration  the  pains  generally  increase  greatly 
in~Torce  and  frequency,  and  if  the  head  be  lovv  in  the  pelvis,  and 
if  the  soft  parts  offer  no  resistance,  the  labor  may  be  rapidly  termi- 
nated. 

Were  its  use  always  followed  by  this  eifect  there  would  be  little  or  no 
objection  to  its  administration.  *The  pains,  however,  are  different  from 
those  of  natural  labor,  being  strong,  persistent,  and  constant.^  Its  effect, 
indeed,  is  to  produce  that  very  state  of  tonic  and  persistent  uterine  con- 
traction which  has  already  been  pointed  out  as  one  of  the  chief  dangers 
of  protracted  labor.  Hence,  if  from  any  cause  the  exhibition  of  the 
drug  be  not  followed  by  rapid  delivery,  a  condition  is  produced  which 
is  serious  to  the  mother  and  which  is  extremely  perilous  to  the  child, 
on  account  of  the  tonic  contraction  of  the  muscular  fibres  obstructing 
the  utero-placental  circulation.  Dr.  Hardy  found  that  soon  the  foetal 
pulsations  fall  to  100,  and  if  delivery  be  long  delayed  they  commence 
to  intermit.  He  also  observed  that  when  this  occurred  the  child  was 
always  born  dead,  ^nd  found  that  the  number  of  stillborn  children 
after  ergot  has  been  exhibited  w^as  very  large)  for  out  of  30  cases  in 
Avhich  he  gave  it  in  tedious  labor,  only  10  of^the  children  were  born 
alive.  ( Nor  is  its  use  by  any  means  free  from  danger  to  the  mother : 
a  not  inconsiderable  number  of  cases  of  rupture  of  the  uterus  have 
been  attributed  to  its  incautious  use.  )  Hence,  if  it  is  to  be  given  at 
all,  it  is  obvious  that  it  must  be  with  strict  limitations  and  after  careful 
consideration,  /it  is  worthy  of  note  that  in  the  Rotunda  Hospital  in 
Dublin  the  use  of  ergot  as  an  oxytocic  before  delivery  has  been  pro-  ' 
hibited  by  the  present  master.  / 

The  cardinal  point  to  remember  is  that  it  is  absolutely  coutraiudicated 
unless  the  absence  of  all  obstacles  to  rapid  delivery  has  been  ascertained. 
Hence,  it  is  only  allowable  when  the  first  stage  is  over  and  the  os  fully 
dilated,  when  the  experience  of  former  labors  has  proved  the  pelvis  to 
be  of  ample  size,  and  when  the  perineum  is  soft  and  dilatable.  Perhaps, 
as  has  been  suggested,  the  administration  of  small  doses  of  from  5  to 
10  minims  of  the  liquid  extract  every  ten  minutes  until  more  energetic 
action  sets  in  might  obviate  some  of  these  risks. 

The  use  of  quinine  as  an  oxytocic  deserves  much  more  attention  than 
it  has  generally  received.  I  frequently  employ  it  in  lingering  labor 
with  marked  benefit,  and  it  does  not  seem  to  have  any  of  the  bad 
effects  of  ergot.  According  to  the  observations  of  Dr.  Albert  H. 
Smith  in  42  cases  of  parturition,  it  presented  the  foUoM'ing  peculiar 
characteristics : 

It  has  no  power  in  itself  to  excite  uterine  contractions,  but  simply 
acts  as  a  general  stimulant  and  promoter  of  vital  energy  and  func- 
tional activity. 

In  normal  labor  at  full  term  its  administration  in  a  dose  of  fifte^p 
grains  is  usually  followed  in  as  many  minutes  by  a  decidecPincrease  in 


350  LABOR. 

the  lorcc  and  iV('(|iu'iH  y  of  the  uterine  contractions,  changing  in  some 
instanees  a  tedious,  cxliaustiuii-  lalxir  into  one  of  rapid  energy,  advan- 
cing to  an  early  completion. 

it  promotes  the  j)ermanent  tonic  contraction  of  the  uterus  after  the 
expulsion  of  tlie  placenta,  women  that  had  flooded  in  former  labors 
escaping  entirely,  there  not  having  been  an  instance  of  post-partura 
heniori'liage  in   the  whole  42  cases. 

Jt  also  diminishes  the  lochial  flow  where  it  had  been  excessive  in 
former  labor's,  the  change  being  remarked  upon  by  the  patient^,  and 
consequently  lessens  the  severity  of  the  after-pains. 

Cinchonism  is  very  rarely  observed  as  an  eflect  of  large  doses  in 
parturient  women.'  i 

Use  of  the  Faradic  Current. — -riie  faradic  current  applied  on  either] 
side  of  the  uterine  tumor,  midway  between  the  anterior  superior  sj)ine, 
of  the  ilium  and  the  umbilicus,  has  recently  been  strongly  recommended 
by  Dr.  Kilner,^  not  only  as  a  means  of  increasing  uterine  action,  but' 
of  alleviating  the  sufl^erings  of  childbirth.)  I  have  tried  it  in  several 
cases,  but  am  not  satisfied  as  to  it«  possessing  the  properties  attributed 
to  it. 

If  MC  had  no  other  means  of  increasing  defective  uterine  contrac- 
tions at  our  disposal,  and  if  the  choice  lay  only  between  the  use  of 
ergot  and  instrumental  delivery,  there  might  not  be  so  much  objection 
to  a  cautious  use  of  the  drug  in  suitable  cases.  We  have,  however,  a 
means  of  increasing;  the  force  of  the  uterine  contractions  so  nmch  more 
manageable  and  so  much  more  lesembling  the  natural  process  that  I 
believe  it  to  be  destined  to  entirely  su})ersede  the  administration  of 
ergot.  This  is  the  application  of  manual  pressure  to  the  uterus 
through  the  abdomen — an  expedient  tliat  has  of  late  years  been  much 
used  in  Germany  and  has  begun  to  be  employed  in  English  practice. 
(l  believe,  therefore,  that  ergot  should  be  chiefly  used  for  the  ])urpose 
of  exciting  uterine  contraction  after  delivery,  when  its  ])cculiar  pro- 
perty of  promoting  tonic  contraction  is  so  valuable,  and  that  it  should 
rarely,  if  at  all,  be  employed  betore  the  birth  of  the  child.) 

The  systematic  use  of  uterine  pressure  as  an  oxytocic  Mas  first  promi- 
nently brought  under  the  notice  of  the  profession  by  Kristeller,  under 
the  name  of  "  express! o  fost us,"  aUhough  it  has  been  used  in  various 
forms  from  time  immemorial.  Albucasis,  for  example,  was  clearly 
acquainted  with  its  use,  and  referred  to  it  in  the  following  terms: 
"Cum  ergo  vidcs  ista  signa,  tunc  oportet,  ut  com})rimatur  uterus  ejus 
ut  descendat  embryo  velociter."  There  are  some  curious  obstetric 
customs  among  various  nations  which  probably  arose  from  a  recog- 
nition of  its  value;  as,  for  example,  the  mode  of  delivery  adopted 
among  the  Kalmucks,  where  the  ])atient  sits  at  the  foot  of  the  bed 
while  a  woman,  seated  behind  her,  seizes  her  round  the  waist  and 
squeezes  the  uterus  during  the  pains.  Amongst  the  Ja])anese,  Siamese, 
North  American  Indians,  and  many  other  nations  pressure,  aj)})lied  in 
various  ways,  is  habitually  used. 
V  Kristeller  maintains  that  it  is  possible  to  effect  the  complete  expulsion 

'  Tram.  Coll.  Phys.  PhikuL,  1875,  p.  183. 
^  Obst.  Trans.,  for  1884,  vol.  xxvi.  p.  93. 


PROLONGED  AND  PRECIPITATE  LABORS.  351 

of  the  cliild  I)y  ])r()])erly  a]ipliecl  pressure,  even  when  tlie  pains  are 
entirely  absent  J  Strange  as  this  may  ap])ear  to  those  wlio  are  not 
familiar  witli  the  eifeets  of  pressure,  I  believe  that  under  exceptional 
circumstances,  when  the  pelvis  is  very  capacious  and  the  soft  parts 
oifer  but  slight  resistance,  it  can  be  done.  I  have  delivered  in  this 
way  a  patient  whose  friends  would  not  permit  me  to  apply  the  forceps 
when  1  could  not  recognize  the  existence  of  any  uterine  contraction  at 
all,  the  foetus  being  literally  squeezed  out  of  the  uterus.  It  is  not, 
however,  as  replacing  absent  pains,  but  as  a  means  of  intensifying  and 
prolonging  the  effects  of  deficient  and  feeble  ones,  that  pressure  finds 
its  best  application. 

Its  effects  are  often  very  remarkable,  especially  in  women  of  slight 
build,  where  there  is  but  little  adipose  tissue  in  the  abdominal  walls 
and  not  much  resistence  in  the  pelvic  tissues.  If  the  finger  be  placed 
on  the  head  while  pressure  is  applied  to  the  uterus,  a  very  marked 
descent  can  readily  be  felt,  and  not  infrequently  two  or  three  applica- 
tions will  force  the  head  on  to  the  perineum.  There  are,  however, 
certain  conditions  when  it  is  inapplicable,  and  the  existence  of  which 
should  contraindicate  its  use.  -.  Thus,  if  the  uterus  seem  unusually 
tender  on  pressure,  and,  a  fortiori,  if  the  tonic  contraction  of  exhaus- 
tion be  present,  it  is  inadmissible.  So  also  if  there  be  any  obstruction 
to  rapid  delivery,  either  from  narrowing  of  the  pelvis  or  rigidity"  of 
the  soft  parts,  it  should  not  be  used.  The  cases  suitable  for  its  applica- 
tion are  those  in  which  the  head  or  breech  is  in  the  pelvic  cavity,  and 
the  delay  is  simply  due  to  a  want  of  sufficiently  strong  expulsive 
action. 

( It  may  be  applied  in  two  ways.  The  better  plan  is  to  place  the 
patient  on  her  back  at  the  edge  of  the  bed,  and  spread  the  palms  of 
the  hands  on  either  side  of  the  fundus  and  body  of  the  uterus,  and 
when  a  pain  commences  to  make  firm  pressure  during  its  continuance 
downward  and  backward  in  the  direction  of  the  pelvic  inlet.  As  the 
contraction  passes  off  the  pressure  is  relaxed,  and  again  resumed  when 
a  fresh  pain  begins.  )  In  this  way  each  pain  is  greatly  intensified,  and 
its  effect  on  the  progress  of  the  foetus  much  increased.  It  is  not  essen- 
tial that  the  patient  should  lie  on  her  back.  A  useful,  although  not  so 
great,  amount  of  pressure  can  be  applied  when  she  is  lying  in  the 
ordinary  obstetric  position  on  her  left  side,  the  left  hand  being  spread 
out  over  the  fundus,  leaving  the  right  free  to  w^atch  the  progress  of  the 
presenting  part  jper  vaginam. 

Special  Value  of  Uterine  Pressure.-i-The  special  value  of  this  n 
method  of  treating  ineffective  pains  is,  that  the  amount  and  frequency  j 
of  the  pressure  are  completely  within  the  control  of  the  practitioner)  j 
and  are  capable  of  being  regulated  to  a  nicety  in  accordance  with  the 
requirements  of  each  particular  case.     It  has  the  peculiar  advantage 
of  closely_iinitatijig_the  njitural  means  of  delivery,  and  of  beino;  abso- 
lutely  without  risk,  to.  tHfi-fiilild  ;'nor  is  there  any  reason  to  think  tlia't 
it  is  capable  of  injuring  the  mother.     At  least  I  may  safely  say  that, 
out  of  the  large  number  of  cases  in  which  I  have  used  it,  I  have  never 
seen  one  in  which  I  had  the  least  reason  to  think  that  it  had  proved 
hurtful.     Of  course  it  is  essential  not  to  use  undue  roughness;  firm 


352  LABOR. 

and  cvi'ii  strong  pivssiiro  may  he  ('inj)l()y('(l,  l»ii(  that  can  Ix-  done  willi- 
oiit  heinji;  r<)uii;li,  and,  as  its  applicalion  is  always  iiitorinittent,  there  is 
no  time  for  it  to  iiiHiet  any  injury  on  tlie  uterine  tissues. 

Pressure  is  sj)eoially  valuable  when  it  is  desirable  to  intensify  feeble 
pains.  \  It  may  be  servieeably  employed  when  the  j)ains  are  altotretlier 
absent  to  imitate  and  re[)lace  them,  provided  there  be  nothinti;  but  the 
absence  of  a  ri.s  a  frrr/o  to  prevent  speedy  deliveiy.  In  such  cases  an 
endeavor  should  be  made  to  imitate  tiic  ]niins  as  closely  as  ])ossible  by 
applying  the  pressure  at  intervals  of  four  or  live  minutes,  and  entirely 
relax i no;  it  after  it  has  been  applied  "for  a  few  secoiuls.] 

Instrumental  Delivery. — AVlien  all  these  means  fail  we  have  then 
left  the  resource  of  instrumental  aid,  and  we  liave  now  to  consider  the 
indications  for  the  use  of  the  forceps  under  such  circumstances.  It  has 
been  already  pointed  out  tliat  professional  opinion  on  this  point  has 
been  undergoing  a  marked  change,  and  that  it  is  now  recognized  as  an 
axiom  by  the  most  experienced  teachers  that  when  we  are  once  con- 
vinced tliat  the  natural  efforts  are  failing,  and  are  unlikely  to  effect 
delivery  except  at  the  cost  of  long  delay,  it  is  far  better  to  interfere 
soon  rather  than  late,  and  thus  pi'evcnt  the  occurrence  of  the  serious 
symptoms  accompanying  protracted  labor.'\  '^fhe  recent  important 
debate  on  the  use  of  the  forceps  at  the  Obstetrical  Society  of  London 
remarkably  illustrated  these  statements,  for  while  there  was  much 
difference  of  opinion  as  to  the  advisability  of  applying  the  forceps 
Avhen  the  head  was  high  in  the  jielvis,  a  class  of  cases  not  now  under 
consideration, ^it  was  very  generally  admitted  that  the  modern  teaching 
was  based  on  correct  scientific  groundsel  This  is,  of  course,  directly 
opposed  to  the  view  so  long  taught  in  our  standard  works,  in  which  in- 
strumental interference  was  strictly  prohibited  unless  all  hope  of  natural 
delivery  was  at  an  end ;  and  in  which  the  commencement  at  least,  if 
not  the  complete  estal^lishment,  of  symptoms  of  exhaustion  was  con- 
sidered to  be  the  only  justification  for  the  apjjlication  of  the  forceps  in 
lingering  labor. 

The  reasons  which  have  led  the  late  di.stinguished  master  of  the 
Rotunda  Hospital  to  a  more  frequent  use  of  the  forceps  are  so  well 
exj^rcssed  in  his  report  for  1872  that  I  venture  to  quote  them  as  the 
best  justification  for  a  practice  that  many  jiractitioncrs  of  the  older 
school  will  no  doubt  be  inclined  to  condemn  as  rash  and  hazardous. 
He  says:^  "  Our  established  rule  is  that  so  long  as  nature  is  able  to 
effect  its  purpose  without  prejudice  to  the  constitution  of  the  i)atieut, 
danger  to  the  soft  parts  or  the  life  of  the  child,  we  are  in  duty  bound 
to  allow  the  labor  to  proceed;  but  as  soon  as  m'C  find  the  natural  efforts 
are  beginning  to  fail,  and  after  having  ti'icd  the  milder  means  for  relax- 
ing the  ])arts  or  stinudating  the  uterus  to  increased  action,  and  the 
desired  effects  not  being  produced,  we  consider  we  are  in  duty  l)ound 
to  adopt  still  promjiter  measures,  and  by  our  timely  assistance  relieve 
the  sufferer  from  her  distreas  and  her  offspring  from  an  innnineut 
death.  Why,  may  I  ask,  should  w^e  permit  a  fellow-creature  to  under- 
go hours  of  torture  when  we  have  the  means  of  relieving  her  within 
our  reach  ?     Why  should  she  be  allowed   to  waste  her  strength  and 

*  Fourth  Clinical  Report  of  the  Rotunda  Lying-in  Hospital  for  the  Year  ending  1872. 


PROLONGED   AND   PRECIPITATE- LABORS.  353 

iiiour  tlio  risks  consc^qiicul  upon  long  [)ressurc  of  the  head  on  the  soft 
parts,  the  tendency  to  inflammation  and  sloughing,  or  the  danger  of 
rupture,  not  to  speak  of  the  poisonous  miasma  which  emanates  from 
au  inflammatory  state  of  the  passages,  the  result  of  tedious  labor,  and 
which  is  one  of  the  fertile  causes  of  puerperal  fever  and  all  its  direful 
effects,  attributed  by  some  to  the  influence  of  being  confined  in  a  large 
maternity,  and  not  to  its  proper  source — I.  e.  the  labor  being  allowed 
to  continue  till  inflammatory  symptoms  appear  ?  The  more  we  con- 
sider the  benefits  of  timely  interference  and  the  good  results  which 
follow  it,  the  more  are  we  induced  to  pursue  the  system  we  have  adopted, 
and  to  inculcate  to  those  we  are  instructing  the  advantages  to  be  gained 
by  such  practice,  both  in  saving  the  life  of  the  child  as  well  as  securing 
the  greater  safety  of  the  mother."  It  would  be  impossible  to  put  the 
matter  in  a  stronger  or  clearer  light,  and  I  feel  confident  that  these 
views  will  be  indorsed  by  all  who  have  adopted  the  more  modern 
practice.  / 

Effect  of  Early  Interference  on  the  Infantile  Mortality.— lln  the/ 
first  edition  of  this  work  I  used  the  statistics  of  Dr.  Hamilton  of  Fal- 
kii-k  and  other  modern  writers  as  proving  that  a  more  frequent  use  of 
the  forceps  than  had  been  customary  diminished  in  a  remarkable  degree 
the  infantile  mortality. j  Dr.  Galabin^  has  recently  published  au  admir- 
able paper  on  this  subject,  in  which,  by  a  careful  criticism  of  these 
figures,  he  has,  I  think,  proved  that  the  conclusions  drawn  from  them 
are  open  to  doubt,  and  that  the  saving  of  infantile  life  following  more 
frequent  forceps  delivery  is  by  no  means  so  great  as  I  had  supposed. 
Dr.  Roper  in  his  remarks  in  the  recent  debate  in  the  Obstetrical 
Society  brought  forward  some  strong  arguments  in  support  of  the 
same  view.  This,  however,  does  not  in  any  way  touch  the  main 
points  at  issue  referred  to  in  the  preceding  paragraph. 

Possible  Dangers  attending-  the  Use  of  the  Forceps. — It  is,  of 
course,  right  that  we  should  consider  the  opposite  point  of  view,  and 
reflect  on  the  disadvantages  which  may  attend  the  interference  advo-  I 
cated.  (Here  I  should  point  out  that  I  am  now  talking  only  of  the  use 
of  the  forceps  in  simple  inertia,  when  the  head  is  low^  in  the  pelvic 
cavity,  alad  when  all  that  is  wanted  is  a  slight  vis  tc  fronte  to  supple- 
ment the  deficient  vis  a  terr/o.J  The  use  of  the  instrument  when  the 
head  is  arrested  high  in  the  pelvis,  or  in  cases  of  deformity,  or  before 
the  OS  uteri  is  completely  expanded,  is  an  entirely  different  and  much 
more  serious  matter,  and  does  not  enter  into  the  present  discussion. 
The  chief  question  to  decide  is  if  there  be  sufficient  risk  to  the  mother 
to  counterbalance  that  of  delay.  It  will,  of  course,  be  conceded  by 
all  that  the  forceps  in  the  hands  of  a  coarse,  bungling,  and  ignorant 
})ractitioner,  who  has  not  studied  the  proper  mode  of  operating,  may 
easily  inflict  serious  damage.  The  possibility  of  inflicting  jnjury  in 
this  way  should  act  as  a  warning  to  every  obstetrician  to  make  him- 
self thoroughly  acquainted  with  the  proper  mode  of  using  the  instru- 
ment, and  to  acquire  the  manual  skill  which  practice  and  the  study 
of  the  mechanism  of  delivery  will  alone  give;  but  it  can  hardly  be 
used  as  an  argument  against  its  use.     If  that  were  admitted,  surgiciil 

'  Obstetrical  Journal,  1877-78,  vol.  v.  p.  561. 
23 


3')4  LA  1:01:. 

inter IVti'IU'c   ol"  any  kind    would    hi-   lal)(M»e'd,  since  there   is  n(»ne  that 
iu,iu)ranee  and   inea|)a('ity   inii^ht   not  render  danirerous. 

Assnniin<j;,  therefore,  that  tlie  practitioner  is  aide  to  apply  the  I'oreeps 
skilfully,  is  there  any  inherent  danger  iu  its  use?  I  think  all  who  dis- 
passionately consider  the  (piestion  must  admit  that  in  the  class  ot" eases 
alluded  to  the  operation  is  so  simple  that  its  disadvantaj^e.s  cannot  i'or  a 
moment  l)e  weighed  against  those  attending  protraction  and  its  eonse- 
(piences.  Against  this  conclusion  statistics  may  possibly  be  (juoted, 
such  as  those  of  C'hurchill,  who  estimated  that  one  in  twenty  mothers 
delivered  by  forceps  in  l^ritish  practice  were  lost.  But  the  fallacy  of 
such  figures  is  apj)arent  on  the  slightest  consideration  ;  and  by  no  one 
has  this  been  more  conclusively  shown  than  by  Drs,  Kicks  and  Phillips 
in  their  pa])er  on  tables  of  mortality  after  obstetric  operations/  where  it 
is  proved  in  the  clearest  manner  that  such  results  are  due  not  to  tlie 
treatment,  but  rather  to  the  fact  tliat  the  treatment  was  so  long 
delayed. 
\  It  is  (juite  impossible  to  lay  down  anv  precise  rule  as  to  when  the  for- 
ceps should  be  used  in  uterine  inertia.  Each  case  nmst  be  treated  on  its 
own  merits  and  after  a  careful  estimate  of  the  effects  of  the  pains.  ■  The 
rules  generally  taught  were  that  the  head  should  be  allowed  to  rest  at  or 
near  the  perineum  for  a  number  of  hours,  and  that  interference  was 
contraindicated  if  the  slightest  progress  were  being  made.  It  is  needless 
to  say  that  both  of  tliese  rules  are  incom])atible  Avith  the  views  I  have 
been  inculcating,  and  that  any  rule  based  upon  the  length  of  time  the 
second  stage  of  labor  has  lasted  must  necessarily  be  misleading.  A\'hat 
has  to  be  done,  I  conceive,  is  to  watch  the  ]>rogress  of  the  case  anxiously 
after  the  second  stage  has  fairly  conmienced,  and  to  be  guided  by  an 
estimate  of  the  advance  that  is  being  made  and  the  character  of  the 
])ains,  beoring  in  mind  that  the  risk  of  the  mother,  and  still  more  to  the 
child,  increases  seriously  with  each  hour  that  elapses.  |  If  we  find  the 
})rogress  slow  and  unsatisfactory,  the  j)ains  flagging  and  nisiiflicicnt.  and 
incapable  of  being  intensified  by  the  means  indicated,  then,  provitlcd  the 
head  be  low  in  the  pelvis,  it  is  better  to  assist  at  once  by  the  forceps, 
rather  than  to  wait  uiiTTl  we  are  driven  to  do  so  by  the  state  of  the 
patient.-  * 

'  Obxt.  Tranx.,  1872,  vol.  xiii.  p.  55. 

^  It  may,  perhaps,  be  of  interest  in  connection  witli  this  important  topic  in  practical 
midwifery  if  I  rcjjrint  a  letter  I  published  some  years  ago  in  the  Medical  Timea  and 
fkizette.  An  historical  case,  snch  as  that  of  which  it  treats,  will  l)etter  illustrate  the 
evil  effects  that  may  follow  nnnecessary  delay  than  any  amonnt  of  argument.  It  seems 
to  me  impo.ssible  to  read  the  details  of  the  delivery  it  describes  withont  being  f()rcii)ly 
struck  with  the  disastrous  results  which  followed  the  practice  adopted,  which,  however, 
was  strictly  in  accordance  with  that  considered  correct,  up  to  a  quite  recent  date,  l>y  the 
highest  obstetric  authorities: 

ON  THE   DEATH   OF   THE   PRINCESS   CHARLOTTE  OF    WALES. 

(Ti>  the  Editor  of  the  Medical  Times  and  Gazette.) 

Sir:  The  letter  of  your  correspondent,  "  An  Old  .\ccoucheur."  regarding  the  death 
of  the  Princess  Charlotte,  raises  a  question  of  great  interest — vi/.  whether  the  fatal 
result  might  have  been  averted  under  other  treatment?  The  liistory  of  the  ca.sc  is 
most  in.structive,  and  I  think  a  careful  cousidcratiou  of  it  leaves  little  room  to  doubt 
that,  though  the  management  of  the  labor  w;us  ipiite  in  accordance  with  the  teaching 
of  tlie  day,  it  was  entirely  opposed  to  that  of  modern  obstetric  science.     The  following 


PROLONUK])  AND  PRECIPITATE  LABORS.  355 

[The  late  Dr.  William  Harris  of  Philadelphia  said  to  the  writer  more 
than  twenty-five  years  ago  :  "I   am  in  the  hahit  of  using  the  forceps 

account  of  the  labor  uuiy  interest  your  readers,  ami  will  jjrohably  he  new  to  most  of 

them.     It  is  contained  iii  a  letter  from  Dr.  John  8ims  to  the  late  Dr.  Joseph  Clarke 

of  Dublin : 

"  London,  November  15, 1817. 

"  My  de.vr  Sir  :  I  do  not  wonder  at  your  wishing  to  have  a  direct  statement  of  the 
labor  of  Her  Royal  Highness  the  Princess  Charlotte,  the  fatal  issue  of  which  has 
involved  the  whole  nation  in  distress.  You  must  excuse  my  being  very  ccmcise,  as  I 
have  been,  and  am,  very  much  hurried.  1  take  the  opportunity  of  writing  this  in  a 
Iving-in  chamber.  Her  Royal  Highness'  labor  commenced  by  the  discharge  of  the 
li(|U()r  anniii  about  seven  o'clock  on  Monday  evening,  and  the  pains  ibllowed  soon 
after.  They  continued  through  the  night  and  a  greater  part  of  the  next  day — sharp, 
soft,  but  very  inettectual.  Toward  the  evening  Sir  Richard  Croft  began  to  suspect  that 
labor  wouldnot  terminate  without  artilicial  assistance,  and  a  message  was  despatched 
for  me.  I  arrived  at  two  on  Wednesday  morning.  The  labor  was  now  advancing 
more  favorably,  and  both  Dr.  Baillie  and  myself  concurred  in  the  opinion  that  it 
would  not  be  advisable  to  inform  Her  Royal  Highness  of  my  arrival.  From  this  time 
to  the  end  of  her  labor  the  progress  was  uniform,  though  very  slow,  the  patient  in  good 
spirits,  the  pulse  calm,  and  there  never  was  room  to  entertain  a  question  about  the  use 
of  instruments.  About  six  in  the  afternoon  the  discharge  became  of  a  green  color, 
which  led  to  a  suspicion  that  tiie  child  might  be  dead;  still,  the  giving  assistance  was 
quite  out  of  the  question,  as  the  pains  now  became  more  efl'ectual,  and  the  labor  pro- 
i'eeded  regularly,  though  slowly.  The  child  was  born  without  artificial  assistance  at 
nine  o'clock  in  the  evening.  Attempts  were  made  for  a  good  while  to  reanimate  it  by 
inflating  the  lungs,  friction,  hot  baths,  etc.,  but  without  effect ;  the  heart  could  not  be 
made  to  beat  even  once.  Soon  after  delivery  Sir  Richard  Croft  discovered  that  the 
uterus  was  contracted  in  the  middle  in  the  hour-glass  form,  and  as  some  hemorrhage 
commenced,  it  was  agreed  that  the  placenta  should  be  brought  away  by  introducing 
the  liand.  This  was  done  about  half  an  hour  after  tlie  delivery  of  the  child  with  more 
«ase  and  less  blood  than  usual.  Her  Royal  Highness  continued  well  for  about  two 
hours  ;  she  then  complained  of  being  sick  at  stomach  and  of  noise  in  the  ears,  began  to 
be  talkative,  and  her  pulse  became  frequent ;  but  I  understand  she  was  very  quiet 
after  this  and  her  pulse  calm.  About  half-past  twelve  o'clock  she  complained  of 
severe  pain  in  the  chest,  became  extremely  restless,  with  rapid,  weak,  and  irregular 
pulse.  At  this  time  I  saw  her  for  the  finst  time.  It  has  been  said  that  we  had  all 
gone  to  bed,  but  that  is  not  a  fact ;  Croft  did  not  leave  her  room,  Baillie  retired  about 
eleven,  and  I  went  to  my  bedchamber  and  laid  down  in  my  clothes  at  twelve.  By 
dissection  some  bloody  fluid  (two  ounces)  was  found  in  the  pericardium,  supposed  to 
be  thrown  out  in  ariiculo  mortis.  The  brain  and  other  organs  all  sound,  except  the 
right  ovarium,  which  was  distended  into  a  cyst  the  size  of  a  hen's  egg.  The  hour- 
glass contraction  of  the  uterus  still  visible,  and  a  considerable  quantity  of  blood  in  the 
cavity  of  the  uterus — but  those  present  dispute  about  the  quantity,  so  much  as  from 
twelve  ounces  to  a  pound  and  a  half — her  uterus  extending  as  high  as  her  navel.  The 
cause  of  Her  Royal  Highness'  death  is  certainly  somewhat  obscure  ;  the  symptoms 
were  sucli  as  attend  death  from  hemorrhage,  but  the  loss  of  blood  did  not  seem  to  be  suf- 
ficient to  account  for  a  fatal  issue.  It  is  possible  that  the  effusion  into  the  pericardium 
took  place  earlier  than  was  supposed,  and  it  does  not  seem  to  be  quite  certain  that  this 
juight  not  be  the  cause.  That  I  did  not  see  Her  Royal  Highness  more  early  was  awk- 
ward, and  it  would  have  been  better  that  I  had  been  introduced  before  the  labor  was 
expected  ;  and  it  should  have  been  understood  that  when  labor  came  on  I  should  be 
.sent  to  without  waiting  to  know  whether  a  consultation  was  necessary  or  not.  I 
thought  so  at  the  time,  but  I  could  not  propose  such  an  arrangement  to  Croft.  But 
this  is  entirely  entre  nous.  I  am  glad  to  hear  that  your  son  is  well,  and,  with  all  my 
family,  wisli  to  be  remembered  to  him.  We  were  liappy  to  hear  that  he  was  agreeably 
nuirried. 

"  I  remain,  my  dear  doctor, 

"  Ever  yours  most  truly, 

"  John  Sijis,  M.  D. 

"  This  letter  is  confidential,  as  perhaps  I  might  be  blamed  for  writing  any  particu- 
lars without  the  permission  of  Prince  Leopold." 

What  are  the  facts  here  shown  '.'     Here  was  a  delicate  young  wonuui,  prepared  for 


3r)()  i.M-.oi:. 

\vv\  <V((|iu'iiily  ill  my  ]»r:icti(c  !<•  iiid  in  llic  delivery  of  dclicatt' \V(iiik-ii  : 
1  would  not  like  it  to  be  gciu-inlly  known,  I'or  I'etir  that  it  might  be 
imitated  by  the  unskiH'ul ;  but  1  use  the  instrument  in  about  one  (Hit 
ol'  seven  cases  of"  labor."  In  no  fbrcej^s  case  had  he  a  death  among  his 
own  patients  in  thirty  yt-ars. — El>.] 

Pi'ecipitate  Labor  less  Common  than  Ling-ering.-^Undue  i'a|)idity 
of  lai)or  is  certainly  more  unconuuon  than  its  converse,  but  still  it  is  by 
no  means  of  iuifre(|uent  occurrence. \  ]\Iost  obstetric  works  contain  a 
Ibrmidable  catalogue  of  evils  that  may  attend  it,  such  as  ru^jture  of  the 
cervix,  or  even  of  the  uterus  itself,  from  the  violence  of  the  uterine 
action  ;  laceration  of  the  perineum  from  the  presenting  part  being 
driven  through  before  dilatation  has  occun-ed  ;  fainting  from  the  sud- 
den eni])tying  of  the  uterus  ;  hemorrhage  from  the  same  cause.  A\'ith 
regard  to  the  child,  it  is  held  that  the  ])ressure  to  which  it  is  subjected, 
and  sudden  expulsion  while  the  mother  is  in  the  erect  position,  may 
prove  injurious.  Without  denying  that  these  results  may  possibly 
occur  now  and  again,  in  the  majority  of  cases  over-rapid  labor  is  not 
attended  with  any  evil  effects. 

Precipitate  labor  may  generally  be  traced  to  one  of  two  conditions,  dr 

the  trial  before  her,  as  Baron  Stockmar  tells  us,  by  "  lowering  the  organic  strength  of 
the  mother  by  bleeding,  aperients,  and  low  diet,"  who  was  allowed  tf)  go  on  in  linger- 
ing feeble  labor  for  no  less  than  fifty-lwo  hours  after  the  escape  of  the  ]i(|uor  aninii  I 
Siieh  was  tlie  groundless  dread  of  instrumental  interference  then  j)revalent  that, 
although  the  case  dragged  on  its  weary  length  with  feeble,  ineHeotual  pains,  every  now 
and  tlien  increasing  a  little  in  intensity  and  then  falling  ofi'again,  it  is  stated  "  there  never 
was  room  to  entertain  a  question  about  the  use  of  instruments,"  and  even  "  when  tlie 
discharge  became  of  a  green  color,  ....  still,  the  giving  assistance  was  cjuite  out  of 
the  question  "  !  Can  any  reasonable  man  doubt  that  if  the  forcejjs  had  been  enqiloyed 
hours  and  hours  before — say  on  Tuesday,  when  the  pains  fell  otl' — tlie  result  would 
probaljly  have  been  very  different,  and  that  the  life  of  tiie  cliild,  destroyed  l)y  tlie 
enormously  prolonged  second  stage,  would  have  been  saved?  It  nnist  be  remend)ered 
that  early  on  Tuesday  morning  delivery  was  expected,  so  that  the  head  nuist  then  liave 
been  low  in  the  pelvis  [ride  Stockniar's  Memoirs,  vol.  i.  ]>.  63).  It  would  be  difficult  to 
tind  a  case  which  more  forcibly  illustrates  the  danger  of  delay  in  the  second  stage  of 
labor.  Tiien  what  follows  ?  The  uterus,  exhausted  by  the  lengthy  eHbrts  it  should 
have  been  spared,  fails  to  contract  eflectually,  nor  do  we  hear  of  any  attemjits  to  pro- 
duce contraction  by  pressui'e.  Tiie  relaxed  organ  becomes  full  of  clots  extending  up 
to  the  imibilicus,  and  all  the  most  characteristic  symptoms  of  concealed  posl-jiartum 
hemorrhage  develop  themselves.  She  complained  "of  being  sick  at  stomach,  and  of 
noise  in  her  ears,  began  l<j  be  talkative,  and  her  j)ulse  became  freciuent."  IJefore  long 
other  symptoms  came  on,  graphically  descril)cd  by  Baron  Stockmar,  and  which  seem 
to  jK)int  to  the  formation  of  a  clot  in  the  heart  and  pulmonary  arteries — a  most  likely 
occurrence  after  such  a  liistory.  "Baillie  sent  me  word  that  he  wished  me  to  see  tlie 
princess.  I  hesitated,  but  at  last  went  with  him.  She  was  suHering  from  sj)asinsof  tiie 
chest  and  difliculty  of  breathing,  in  great  pain,  and  very  restless,  aiul  threw  herself 
continually  from  one  side  of  the  bed  to  the  other,  speaking  now  to  Baillie,  now  to 
Croft.  Baillie  said  to  her,  '  Here  comes  an  old  friend  ol"  yours.'  She  held  out  her  left 
hand  to  me  hastily,  and  pressed  mine  warmly  twice.  1  felt  her  pulse  ;  it  was  going 
vei-y  fast — the  beats  now  strong,  now  feeble,  now  intermittent." 

Here  was  evidently  something  dilioicnl  from  the  exhaustion  of  hemorrhage  ;  and  no 
one  who  lias  witnessed  a  ca.se  of  pulmonary  obstruction  can  fail  to  recognize  in  this 
account  an  accurate  delineation  of  its  dreadful  symptoms. 

Surely  this  lamentable  story  can  only  lead  to  the  conclusion  that  the  unhajipy  and 
gifted  jirincess  fell  a  victim  to  the  tlread  of  that  bugbear,  "  meddlesome  midwifery," 
which  has  so  long  retarded  the  progress  of  obstetrics. 

1  am,  etc., 

W.  S.  Playfair. 

Curzoii  Street,  Muyfair,  W.,  November  29,  187'J. 


PROLONGED  AND  PRECIPITATE  LABORS.  357 

to  u  conihinatioii  of  hoth-^excessive  force  and  rapidity  of  the  paii)s|oi:. 
(^umisiial  laxity  and  want  of  resistance  of  tlie  soft  ])arts.\  The  precise 
<'auses  indiicino-  tiiese  it  is  diili(;uh  to  estimate.  In  some  cases  tlie  for- 
mer may  depend  on  an  undue  amount  of  nervous  excitability,  and  the 
latter  on  the  constitutional  state  of  the  patient  tending  to  relaxation  of 
the  tissues. 

[As  an  instance  of  rapid  delivery,  I  report  the  following  case :  In 
Sejitember,  1848,  a  3-para  of  27,  in  Philadelphia,  was  awakened  in  the 
night  by  a  violent  uterine  pain,  followed  at  once  by  a  sensation  of 
approaching  delivery.  Her  husband,  a  noted  accoucheur,  was  only  u]) 
in  time  to  receive  the  foetus,  which  came  by  the  same  pain  that  awakened 
his  wife.  A  second  foetus  (both  females)  soon  followed,  and  the  whole 
labor,  in  all  its  stages,  occupied  but  forty-five  minutes.  In  two  prior 
and  two  subse(|uent  labors  there  was  no  marked  haste  in  uterine  action. 
Tiie  mother,  who  still  lives,  has  never  been  a  strong  woman. — Ed.] 

Whatever  the  cause,  the  exti'eme  rapidity  of  labor  is  occasionally 
remarkable,  and  one  strong  pain  may  be  sufficient  to  effect  the  expul- 
sion of  the  child,  with  little  or  no  preliminary  warning.  'l  have  known 
a  child  to  be  expelled  into  the  pan  of  a_watei'-clq,set,  the  only  previous 
indication  of  commencing  laborlBiemg  a  slight  griping  pain  which  led 
the  mother  to  fancy  that  an  action  of  the  bowels  was  about  to  take 
place.  ^More  often  there  is  what  may  be  described  as  a  storm  of  ute- 
rine contractions,  one  pain  following  the  other  with  great  intensity  until 
the  foetus  is  expelled}  The  natural  effect  of  this  is  to  produce  a  great 
amount  of  alarm  or  nervous  excitejnent,  which  of  itself  forms  one  of  the 
worst  results  of  this  class  of  labor.  It  is  under  such  circumstances  that 
temporary  mania  occurs,  produced  by  the  intensity  of  the  suffering,  under 
which  the  patient  may  commit  acts  her  responsibility  for  which  may 
fairly  be  open  to  question. 

Little  Treatment  Possible. — Little  can  be  done  in  treating  undue 
rapidity  of  labor.  vWe  can,  to  some  extent,  modify  the  intensity  of  the 
pains  by  urging  the  patient  to  refrain  from  voluntary  efforts  and  to 
open  the  glottis  by  crying. out,  so  that  the  chest  may  no  longer  be  a 
fixed  point  for  muscular  action.'^  '^Opiates  have  been  advised  to  control 
uterine  action,  but  it  is  needless  to  point  out  that  in  most  cases  there  is 
no  tiiiie  for^ihem  to  take  effect.  Chloroform  will  often  be  found  most 
valuable^  from  the  rapidity  with  which  it  can  be  exhibited  ;  and  its 
power  of  diminishing  uterine  action,  which  forius  one  of  its  chief  draw- 
backs in  ordinary  practice,  will  here  prove  of  much  service. 


358  LABOR. 


CHAPTER  X. 
LABOR  obstructi<:d  by   faulty  condition  of  the  soft 

PARTS. 

Rigidity  of  the  Cervix  a  Frequent  Cause  of  Protracted  Labor. 
— One  of  the  most  frcciiu'iit  oaiiscs  of  delny  in  tlio  first  stage  of  labor 
is  rigidity  of  the  cervix  iitci'i,  which  may  (le])end  on  a  varictv  of  con- 
ditioiis.  Ut  is  often  ])ro(luccd  by  premature  escape  of  tlie  li(jUor  aninii, 
in  consequence  of  Avliich  the  fluid  wedge,  which  is  Nature's  means  of 
dilating  the  os,  is  destroyed,  and  the  hard  presenting  part  isconsequently 
brought  to  bear  directly  upon  the  tissues  of  the  cervix,  which  are  thus 
unduly  irritated  and  thrown  into  a  state  of  spasmodic  contractioil\  At 
other  times  it  may  be  due  to  constitutional  peculiarities,  among  which 
there  is  none  so  common  as  a  highly  nervous  and  emotional  tenipcra- 
nient,  which  renders  the  patient  peculiarly  sensitive  toTier  sufferings  and 
interferes  with  the  harmonious  action  of  the  uterine  fibres.  The  pains 
in  such  cases  cause  intense  agony,  are  short  and  cramp-like  in  character, 
but  have  little  or  no  effect  in  producing  dilatation,  the  os  often  remain- 
ing for  many  hours  without  any  appreciable  alteration,  its  edges  being 
thin  and  tightly  stretched  over  the  head.  Less  often — and  this  is  gen- 
erally met  with  in  stout,  plethoric  women — the  edges  of  tlie  osare  thick 
and  tough. 

The  effects  of  prolongation  of  labor  from  this  cause  will  vary  much 
under  different  circumstances.  If  the  liquor  anmii  be  prematurely 
evacuated,  the  presenting  part  presses  directly  upon  the  cervix,  and  the 
case  is  then  practically  the  same  as  if  the  labor  was  in  the  second  stage. 
Hence  grave  symptoms  may  soon  develop  themselves,  and  early  interfer- 
ence may  be  imperatively  demanded.  If  the  membranes  be  unrui)tured, 
delay  will  be  of  comparatively  little  moment,  and  considerable  time 
may  elapse  without  serious  detriment  to  either  the  mother  or  child. 

The  treatment  will  naturally  vary  nnich  Avith  the  cause  and  the 
state  of  the  jnitient.  In  tlse  majority  of  cases,  es])ecially  if  the  mem- 
Ijranes  be  still  intact,  patience  and  time  are  sufficient  to  overcome  the 
obstacle  ;  but  it  is  often  in  the  power  of  the  accoucheur  materially  to  aid 
dilatation  by  appropriate  management.  (Sojuetimes  Nature  overcomes 
the  ol)struction  by  lacerating  the  opposin^r  stru<-tin'cs\  "anct  cases  are  on 
record  in  which  even  a  comj)lete  rmg  of  the  cervix  hrtsbccn  torn  off  and 
come  away  before  the  head. 

]Many  remedies  have  been  recommended  for  facilitating  dilatation, 
some  of  which  no  doubt  act  beneficially.  Limong  those  most  frequently 
resorted  to  was  venesection,  and  with  it  was  generally  associated  the 
administration  of  nauseating  doses  of  tartar  emetic.  Both  these  acted 
bv  producing  tempoi'ary  dej)ression,  under  which  the  resistance  of  the 
soft  parts  was  lessened.  They  probably  answer  best  in  cases  in  which 
there  was  a  rigid  and  tough  cervix,  and  they  might  prove  serviceable 


OBSTRVCTION  FROM  CONDITION  OF  SOFT  PARTS.         .J.'jO 

even  yet  in  stout,  plethoric  wonion  of  rohiist  rranic.  Practicallr,  thcv 
UTdJiow  seldom  if  ever  employed,  and  other  and  loss  debilitatiiiLT  nin- 
ediosare  jtreferred.  The  ajrent,  par  excellence,  most  serviceable  is  chloraL 
Nvhich  is  of  sj)ocial  value  in  the  more  common  cases  in  which  njl^ulity 
is  associated  with  spasmodic  contraction  of  the  muscular  iibres  of  the 
cervix.  Two  or  three  doses  of  15  grains,  repeated  at  interv^als  of 
twenty  minutes,  are  often  of  alniosf  "iiiagical  efficacy,  the  pains  becoming 
steady  and  regular,  and  the  os  gradually  relaxing  sufficiently  to  allow 
the  passage  of  the  head.  Should  the  chloral  1)C  rejected  by  the  stom- 
ach, it  may  be  satisfactorily  administered  per  rectum.  Chloroform 
acts  much  in  the  same  way,  but  on  the  whole  less  satisfactorily,  its 
effects  being  often  too  great;  while  the  peculiar  value  of  chloral  is  its 
influence  in  promoting  relaxation  of  the  tissues  without  interfering  with 
the  strength  of  the  pains. 

Various  local  means  of  treatment  may  be  also  advantageously  used. 
One  is  the  warm  bath,  which  is  much  used  in  France.  It  is  of  unques- 
tionable value  where  there  is  mere  rigidity,  and  may  be  used  either  as 
an  entire  bath,  or  as  a  hi})-bath  in  which  the  patient  sits  from  twenty 
minutes  to  half  an  hour.  The  objection  is  the  fuss  and  excitement  it 
causes,  and  for  this  reason  it  is  an  expedient  seldom  resorted  to  in  this 
country.  A  similar  effect  is  produced,  and  much  more  easily,  by  a 
douche  of  tepid  water  upon  the  cervnx.  This  can  be  very  easily  admin- 
istered, the  pipe  of  a  Higginson's  syringe  being  guided  up  to  the  cervix 
by  the  index  fluger  of  the  right  hand,  and  a  stream  of  water  projected 
against  it  for  five  or  ten  minutes.  Smearing  the  os  with  extract  of 
belladonna  is  advised  by  continental  authorities,  but  its  effects  are  more 
than  doubtful.  Horton  ^  advocates^he  injection  into  the  tissue  of  the 
cervix  of  jj^of^agrain  of  atropine  oy  means  of  a  hypodermic  syringe,) 
and  speaks  very  favorably  of  the  practice. 

Artificial  Dilatation. — Artificial  dilatation  of  the  cervix  by  the 
finger  has  often  been  recom mended,"  "a nd  has  been  the  subject  of 
much  discussion,  especially  in  the  Edinburgh  school,  where  it  was 
formerly  commonly  employed,  It  is  capable  of  being  verv  useful, 
l)ut  it  may  also  do  much  injury  when  roughly  and  injudiciously 
used.  The  class  of  cases  in  which  it  is  most  ser\aceable  are  those 
in  which  the  liquor  amnii  has  been  long  evacuated,  and  in  which 
the  head,  covered  by  the  tightly-stretched  cervix,  has  descended  low 
into  the  pelvic  cavity.  rUnder  these  circumstances,  if  the  finger 
be  passed  gently  within  tue  os  during  a  pain  and  its  margin  pressed 
u[)ward  and  over  the  head,  as  it  were,  while  the  contraction  lasts, 
the  progress  of  the  case  may  be  materially  facilitated.^  This  ma- 
noeuvre is  somewhat  similar  to  that  which  has  been  already  spoken 
of,  when  the  anterior  lip  of  the  cervix  is  caught  between  the  head  and 
the  pubic  bone,  and  if  properly  performed  I  believe  it  to  be  quite  safe 
and  often  of  great  value.  It  is  not,  however,  well  adapted  for  those 
cases  in  which  the  membranes  are  still  intact,  or  in  which  the  os  remains 
undilated  when  the  head  is  still  high  in  the  pelvis.  AVhen  there  is 
much  delay  under  these  conditions,  and  interference  of  some  kind 
seems  called  for,  the  dilatation  may  be  much  assisted  by  the  use  of 

'  Amcr.  Jonrn.  of  Ob^t.,  1878,  vdI.  xi.  p.  482. 


300  LMIOR. 

Ciioutchoiu-  (lilatoi-s,  descrilu'd  in  tlic  cliaptcr  on  the  induction  of  pronia- 
turo  labor,  \\\\n\\  imitate  Xatuir's  method  of  opcnini;  up  the  os,  and 
also  art  as  a  direct  stimulant  to  uterine  contraction.  Hut  it  should  l)e 
rememhcrcd  that  it  is  precisely  in  such  cases  that  delay  is  least  j»n;judi- 
cial.  If,  however,  the  os  l)e  excessively  lonj;  in  opeuin<r,  its  dilatation 
luav  be  safely  and  etiiciently  i)romoted  by  passinjr  within  it  and  tlis- 
tendiui;  with  water  one  of  tlie  smallest-sized  bags;  and  after  this  has 
been  in  position  from  teu  to  twenty  minutes  it  may  Im?  removed,  and  a 
larirer  one  substituted. 

Rigidity  depending  upon  Organic  Causes. — Every  now  and  a<rain 
we  meet  with  ca.ses  in  wlmTi  the  oljstacle  tiepends  u])on  ortraiiic  changes 
in  the  cervix,  the  most  common  of  which  are  cicatricial  hardening  irom 
former  lacerations,  hypertrophic  elongation  of  the  cenix  from  disease 
antecedent  to  j)regnancy,  or  even  agglutination  and  closure  of  the-Lbi- 
uteri.  Cicatrices  are  generally  the  result  of  lacerations  during  former 
laboi"s.  Thev  implicate  a  j)t>rtion  only  of  the  cervix,  which  they  render 
hard,  rigid,  and  uudilatable,  while  the  remainder  has  its  natiu-al  soft- 
ness. They  can  readily  be  made  out  by  the  examining  finger.  A 
somewhat  similar,  but  much  more  formidable,  obstruction  is  occasion- 
ally met  with  in  cases  of  old-standing  hyjiertrophic  elongation  of  the 
cervix,  which  is  generally  associated  with  prolapse.  ^In  most  cases  of 
this  kind  the  cervix  becomes  softened  during  pregnancy,  so  that  dila- 
tation occurs  without  any  unusual  difK<'ulty."S  J>ut  this  does  not  always 
happen.  A  good  example  is  related  by  ]\iix  Roper  in  the  seventh  vol- 
ume of  the  Obstetrical  Transactions  (p.  233),  in  which  such  a  cervix 
formed  an   almost  insuperable  obstacle  to  the  paasage  of  the  child. 

Carcinoma  of  the  cervix  uteri,  which  produces  extensive  thickening 

and  induration  of  its  tissues,  and  even  advanced  malignant  disease  of 

the  uterus,  is  no  bar  to  conception.     The  relations  of  malignant  disease 

to  pregnancy  and  parturition  nave  recently  been  well  studied  by  Dr.  Her- 

<;man.^     He  concludes  that  cancer  renders  the  patient  inapt  to  conceive, 

(but  that  when  pregnancy  does  occur  there  is  a  tendency  to  the  intra- 

/  uterine  death  and  premature  expulsion  of  the  fretus,  and  the  growth  of 

'  the  cancer  is  accelerated.     When  delivery  is  accomplished,  naturally  there 

','is  generally  expansion  of  the  cervix  by  fissuring  of  its  tissue,  but  the 

''harder  forms  of  cancer  may  form  an  insu])erable  obstacle  to  delivery. 

Agglutination  of  the  margins  of  the  os  uteri  is  occasionally  met 
with,  and  must  of  course  have  occurred  after  conception.  It  is  gen- 
erally the  result  of  some  inflammatory  attection  of  the  cervix  during 
the  early  months  of  gestation,  and  1  have  known  it  to  recur  in  the 
same  woman  in  two  successive  ])regnaucics.  ^Usually  it  is  not  asso- 
ciated with  any  hardness  or  rigidity,  but  the  entire  cervix  is  stretche<l 
over  the  presenting  part,  and  forms  a  smooth  covering  in  which  tlie  os 
may  only  exist  as  a  small  dimj)le,  and  may  be^pry  difficult  to  detect 
at  all.  I  Occlusion  of  the  os  uteri  from  inflanunaTcirv  change  sometimes 
so  alters  the  cervix  that  no  sign  of  the  oi'iginal  opening  can  be  dis- 
covered ;  and  in  two  such  instances  the  Ciesarean  ojx'ration  has  been 
performed  in   the  United    Stiites,  by  which  the   women  were  saved.^ 

'  Obst.  Trans.,  for  1878,  vol.  xx.  p.  191. 
'  Harris'  note  to  second  American  edition. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.         301 

Their  Treatment. — Any  ^A  these  iiieclianical  causes  of  rigidity  may 
at  first  be  treated  iu  the  same  way  as  the  more  simple  cases;  and  with 
patience,  tlie  use  of  chloral  and  chloroform,  and  of  the  fluid  (lilators 
sufficient  exj)ansion'^'"permit  the"~passage  of  the  head  will  often  take 
place.  But  if  these  methods  produce  no  effect,  and  symptoms  of  con- 
stitutit)nal  irritation  are  beginning  to  develop  themselves,  other  and 
more  radical  means  of  overcoming  the  obstruction  may  be  requii'cd. 

Under  such  circumstances  iAlcisdau^o^jthe  cervix  niay  be  not  only  jus- 
tifiable, but  essential,  and  it  frequently  answers  extremely  well.  On  the 
Continent  it  is  resorted  to  much  more  frequently  and  earlier  than  in 
England,  and  with  the  most  beneficial  results.  The  operation  offers 
no  difficulties.  The  simplest  way  of  performing  it  is  to  guard  the 
greater  portion  of  the  blade  of  a  straight  blunt-pointed  bistoury  by 
trapping  lint  or  adhesive  plaster  round  it,  leaving  about  half  an  inch  of 
cutting  edge  toward  its  point.  (  This  is  guided  to  the  cervix  on  the  under 
surface  of  the  index  finger,  and  three  or  four  notches  are  cut  in  the  cir- 
cumference of  the  OS  to  about  the  depth  of  a  quarter  of  an  inch.;  Very 
generally,  especially  when  the  obstruction  is  only  due  to  old  cicatrices,  the 
pains  will  now  speedily  effect  complete  expansion,  which  may  be  very 
advantageously  aided  by  applying  the  hydrostatic  dilators.  When  the 
obstruction  is  due  to  carcinomatous  infiltration  or  inflammatory  thick- 
ening, tlie  case  is  much  more  complicated,  and  will  painfully  tax  the 
resources  of  the  accoucheur.  If  it  is  possible,  the  disease  should  be 
removed  as  much  as  can  be  safely  done  during  pregnancy,  which  should 
also  be  brought  to  an  end  before  the  full  period.  During  labor,  incis- 
ions should  form  a  preliminary  to  any  subsequent  proceedings  that  may 
be  necessary,  as  they  are,  at  the  worst,  not  likely  to  increase  in  the  least 
the  risk  the  patient  has  to  run,  and  they  may  possibly  avert  more  serious 
operations.  (In  the  case  of  malignant  disease  tlie  risk  of  serioiis_hmior- 
rhage,  from  the  great  vascularity  of  the  tissues,  must  not  be  forgotten, 
and  if  necessary  means  must  be  taken  to  check  this  by  local  styptics, 
such  as  perchloride  of  iron.")  If  incision  fail  and  the  state  of  the 
patient  demands  speedy  delivery,  the  forceps  juiiv  be  applied ;  and 
Herman  thinks  they  are,  as  a  rule,  better  than  turning.  He  also 
maintains  that  there  is  little  difference  in  the  risk  to  the  mothers  be- 
tween craniotomy  and  Cesarean  section,  and  that  the  possibility  of 
saving  the  child  in  cases  in  which  incisions  have  failed  should  induce 
us  to  prefer  the  latter. 

[The  experience  of  Great  Britain  would  indicate  that  the  Caesarean 
operation  iti  cases  of  cancer  of  the  cervix  gives  a  better  promise  of 
success  than  in  subjects  having  pelvic  deformity.  This  result  is  proba- 
bly due  to  the  operation  in  cases  of  cancer  being  in  many  instances 
elective. — Ed.] 

Application  of  the  Forceps  within  the  Cervix. — Before  perform- 
ing craniotomy,  when  the  os  is  sufficiently  open,  a  cautious  application 
of  the  forceps  is  quite  justifiable.  Steady  and  careful  downward  trac- 
tion, combined  with  digital  ex])ansion,  has  often  enabled  a  head  to  pass 
with  safety  through  an  os  that  lias  resisted  all  other  means  of  dilatation, 
and  the  destruction  of  the  child  has  thus  been  avoided.  If,  indeed,  the  os 
a}>j)ear  to  be  dilatable,  this  procedure  may  advantageously  be  adopted 


362  LABOR. 

ht'i'orc  incision,  and  as  a  nialti-r  ol'  iiict  it  is  coninionly  juactiscd  in  the 
Kotuiula  H<)S])ital.  An  operation  involving,  beyond  doubt,  of  itself 
some  risk,  and  rc(|nirinji-  considerable  o])erative  dexterity,  would  natur- 
ally not  lie  liuhily  and  inconsiderately  undertaken.  J>ut  when  it  is 
remembered  that  the  alternative  is  the  destruction  of  the  child,  tin;  risk 
of  exhaustion,  and  at  least  as  great  mechanical  injury  to  the  mother, 
its  ditliculty  nee<l   not  stand  in   the  way  of  its  adoption. 

Treatment  -when  Occlusion  of  the  Os  Exists. — ^^'hen  the  os  is 
aj)parently  obliterated,  incision  is  the  only  I'esource.  Before  resorting 
to  it  the  })atieiU  should  be  })laced  under  ehlorofbrm  and  the  entire  lower 
■segment  of  the  uterus  carefully  explored.  Possibly  the  aperture  liiay 
be  found  l)igh  up  and  out  of  reach  of  an  ordinary  examination,  or  we 
may  deteet  a  depression  eorresjjonding  to  its  site.  A  small  crueial 
iueision  may  then  be  made  at  the  site  of  the  os,  if  this  can  be  a.scer- 
tained  ;  if  not,  at  the  most  })rominent  portion  of  the  eervix.  A'^ery 
generally  the  pains  will  then  suffice  to  comj)l('te  ex})ansion,  which  may 
be  fui'ther  aided    by   the  fluid   dilators. 

Ante-partum  Hour-glass  Contraction. — Dr.  Hosmer'  has  drawn 
attention  to  a  hitherto  undesoribed  species  of  dystocia  which  he  tenus 
''  u)\te-£)artum  hour-glass  contraction,''  and  which  he  believes  to  depend 
on  constriction  of  the  uteri iie^RBres  at  the  site  of  the  internal  os  uteri. 
[Dr.  Bluudell  (1840)  refers  to  it  in  his  Obstetric  Medicine  under  the 
title  of  '^circular  contraction  of  the  middle  of  the  iroinb''  dividing  it 
as  it  were,  into  an  upjier  and  inferior  chamber,  part  of  the  f(etus 
lying  in  both.  He  had  seen  two  or  three  cases. — Ed.]  Harris^ 
doubts  its  limitation  to  the  internal  os  uteri,  and  terms  it  "  tetanoid 
falciform  constriction  of  the  uterus."  Whatever  its  site,  in  the  cases 
recorded  diffictdties  of  the  most  formidable  kind  arose  from  this  cause. 
The  pelves  were  normal  and  the  presentations  uatiu'al,  yet  out  of  seven 
laliors,  four  ended  fatally,  two  Ix'iore  delivery.  The  constriction  seems 
to  have  grasped  the  foetus  with  such  force  as  to  have  rendered  extraction 
either  by  the  forceps  or  turning  imj)ossible.  I  have  no  personal  experi- 
ence of  this  complication,  which  must  fortunately  be  very  rare.  The 
introduction  of  the  hand,  the  patient  being  decjily  anaesthetized,  would 
])robably  render  diagnosis  easy.  The  treatment  nuist  dc])end  on  the 
force  and  amount  of  constriction.  (Ji'  the  constriction  does  not  relax 
under  chloroform,  chloral,  or  the  injection  of  atroj)ine  into  the  site  of 
constriction,  as  recommended  by  Horton  in  rigidity  of  the  cervix,  U'l'"- 
ing  would  j)i'obably  be  our  best  resource.  Should  this  fail,  the  Ca?sarean 
section  may  be  re(|uired  to  eflect  delivery,  as  hajijiened  in  a  case  recorded 
by  Dr.  T.  A.  Foster  of  Portland,  Maine.  Gastro-elytrotomy  is  obviously 
unsuitable  for  such  cases. 

Bands  and  Cicatrices  in  the  Vagina. — Extreme  rigidity  of  the 
vagi2ia,  or  bands  and  cicatrices  in  or  across  its  walls,  the  result  of  con- 
genital malformation,  of  injuries  in  former  labors,  or  of  antecedent 
disease,  occasionally  obstruct  the  second  stage."  There  is  seldom  any 
really  formidable  dilliculty  from  this  cause,  since  the  ol)struction  almost 
always  yields  tf)  the  jiressure  of  the  j)resenting  part.      If  there  l)e  any 

'  Bimlon  Mi(J.  and  Sinv/.  .Tourn.,  1878,  Marcli  and  May. 
^  Harris'  note  to  second  American  edition. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.  303 

(•(►iisidcrahlo  extent  of  eieatriee.s  in  tlie  vagina,  artifieial  a.ssistancc  niav 
l)e  required,  /if  we  should  be  aware  of  their  existence  during  pregnancy 
and  find  then)  to  be  sufficiently  dense  and  extensive  to  l)e  likelv  to 
interfere  with  delivery,  an  endeavor  may  be  made  to  dilate  them  gradu- 
ally by  hydrostatic  bags  or  bougies.  If  they  be  not  detected  until  labor 
is  in  progress,  we  must  be  guifled  in  our  ])rocedure  by  the  pressure  to 
which  they  are  subjected.  (  It  may  then  be  necessary  to  divide  them  with 
a  knife  and  to  hasten  the  passage  of  the  head  by  the  forceps,  so  as  to  pre- 
vent contusion  as  much  as  possible.  \  It  is  obviously  impossible  to  lay 
down  any  positive  rules  for  such  rare  contingencies,  the  treatment  suit- 
al)le  for  which  must  necessarily  vary  much  with  the  individual  peculiar- 
ities of  the  case. 

Extreme  Rigidity  of  the  Perineum.— (-Extreme  rigidity  of  the  j 
perineum  is  often  dependent  upon  cicatricial  hardening  from  injury  in  ( 
previous  labors.'^  This  condition  may  greatly  interfere  Avith  its  dilata-  ( 
tion,  and  if  laceration  seems  inevitable,  we  may  be  quite  justified  in  / 
attempting  to  avert  it  by  incision  of  the  margins  of  the  perineum, 
on  the  principle  of  a  clean  cut  being  always  preferable  to  a  jagged 
tear.  ' 

Labor  comiplicated  -with  Tumor. — Occasionally  we  meet  with  very 
formidable  obstacles  from  tumors  connected  with  the  maternal  structures. 
These  are  most  commonly  either  fibroid  or  ovarian,  although  others 
may  be  met  with,  such  as  malignant  growths  from  the  pelvic  bones, 
exostoses,  etc. 

Considering  the  frequency  wdth  which  women  suffer  from   fibroid 
tumors  of  the  uterus,  it  is  perhaps  somewhat  remarkable  that  they  do 
not  more  often  complicate  delivery.    (Probably  women  so  affected  are 
not  apt  to  conceive^    Occasionally,  however,  cases  of  this  kind  cause 
much  anxiety.     Of  course  the  cases  are  most  grave  in  which  tumors 
are  so  situated  as  to  encroach  upon  the  cavity  of  the  pelvis  and  mechani- 
cally obstruct  the  passage  of  the  child.    vEven  those  in  which  this  does ) 
not  occur  are  by  no  means  free  from  danger,  for  interstitial  and  subperi-  ] 
toneal  fibroids,  situated  in  the  upper  parts  of  the  uterus  and  leaving  / 
the  pelvic  cavity  quite  unimplicated,  may  interfere  with  the  action  of  ) 
the  uterine  fibres,  prevent  subsequent  contraction,  cause  profuse  post- ' 
partum  hemorrhage,  or  even  predispose  to  rupture  of  the  uterine  tissues.  ' 
Hence,  every  case  in  which  the  existence  of  uterine  fibroids  has  been       > 
ascertained  must  be  anxiously  watched.    [The  nsk  of  bemo_rrliage  is    ^ 
perhaps  the  greatest, '^for  if  the  tumors  be  at  all  Targe' efficient  contrac- 
tion of  the  uterus  after  the  birth  of  the  child  must  be  more  or  less 
interfered  with.     Fortunately,  it  is  not  so  common  as  might  almost  be 
expected.     Out  of  5  cases  recorded  in  the   Ohsfetrical  Transaction.'^,  2 
of  which  were  in  my  own  ]n-actice,  no  hemorrhage  occurred ;  nor  does 
it  seem  to  have  happened  in  any  of  the  26  cases  collected  bv  INIagde- 
laine  in  his  thesis  on  the  subject.    I  recently  saw  an  interesting  example 
of  this  in  a  patient  whose  case  was  looked  forward  to  with  much  anxietv 
in  consequence  of  the  existence  of  several  enormous  fibroid  masses  pro- 
jecting from  the  fundus  and  anterior  surface  of  the  bodv  of  the  uterus, 
and   Avhose   labor  was  nevertheless   typically   normal    in    everv   Avav. 
/  Should  hemorrhage  occur  after  delivery,  the  injection  of  styptic  solutions 


36-1  LAlHiR. 

would  probably  bo  j)e(Miliarly   vahiabic,  since  llic  ordinary  means  of 
promoting:;  contraction  are  likely  to  fail.) 

It  is  when  the  iibroid  ji^rowths  inij)lieiite  the  lower  uterine  zone  and 
the  cervical  region  that  the  greatest  difficulties  are  likely  to  be  met  witii. 
The  j)ractice  then  to  be  adopted  must  be  regulate<l  to  a  great  extent  by 
the  nature  of  each  individual  ca.-c.  vlf  it  be  possible  to  j)ush  the  tumor 
above  the  jiclvic  brim,  out  of  the  way  of  tlu'  presenting  part,  that,  no 
doubt,  is  the  best  course  to  pursue,  as  not  only  clearing  the  passage  in 
the  most  efteetual  May,  but  removing  the  tumor  from  the  bruising  to 
M-hich  it  would  otherwise  l)e  subjected  when  jiressed  between  the  head 
and  the  pelvic  walls;  which  seems  to  be  one  of  the  greatest  dangers  of 
this  eompIicatiouA  This  mananivre  is  sometimes  possible  under  what  seem 
to  be  the  most  unpromising  circumstances.  An  interesting  example  is 
narrated  by  Sir  Spencer  A\"ells,'  who,  called  to  ])erf(^rm  the  Cicsarean 
section,  succeeded,  although  not  without  much  difficulty,  in  pushing  the 
obstructing  mass  above  the  brim,  the  child  subsequently  passing  with 
ease.  I  have  myself  elsewhere  recorded  two  similar  cases ^  in  which  I 
was  enabled  to  deliver  the  patient  by  ])Ushing  \\\)  the  obstructing  tumor, 
in  Ijoth  of  which  the  Oesarean  section  would  have  been  inevitable  had  the 
attem])t  at  reposition  failed.  Therefore,  before  resorting  to  more  serious 
o])erative  procedures  a  determined  effort  at  pushing  the  tumor  out  of 
the  way  should  be  made,  the  patient  being  deej)ly  chloroformed,  and,  if 
necessary,  upward  pressure  being  made  by  the  closed  fist  j)a.ssed  into  the 
vaffina.^ 

u^'ailing  this,  the  possibility  of  enucleating  the  tumor,  or,  if  that  be 
not  possible,  of  i:eiiioviug_it  piecemeal  with  the  ecraseur,  should  be  con- 
sidered. ^On  account  of  theloose  attachments  of  these  growths,  and  the 
facility  with  which  they  can  be  removed  in  this  way  in  the  non-]>reg- 
nant  state,  the  expedient  seems  certainly  well  worthy  of  a  trial  if  their 
site  and  attachments  render  it  at  all  feasil)le.  Interesting  examples  of 
the  successful  i)crformance  of  this  operation  are  recorded  by  Danyau, 
Braxton  Hicks,  Lomer,  and  Munde.  Should  it  be  found  impracticable, 
the  case  must  be  managed  in  reference  to  the  amount  of  obstruction, 
and  the  forcejis,  cjiailiotomy,  or  even  one  of  the  varieties  of  abdominal 
section,  may  be  necessary  [vifle  p.  228). 

[Cesarean  records  in  cases  of  pelvic  obstructions  due  to  fibroid  tumoi-s 
show  a  very  discouraging  mortality.  There  have  been  14  such  ojiera- 
tions  in  the  United  States,  with  only  4  women  and  o  children  saved. 
Add  these  to  31  cjises  collected  in  1882  by  Dr.  Max  Siinger  of  Leipzig 
from  other  countries,  and  we  have  45  cases  with  36  deaths.  An  early 
operation  under  the  Sanger  method  should  be  followed  by  better 
results. — Ei).] 

Tumors  of  the  Ovaries. — The  next  most  common  class  of  obstruct- 
ing tumors  are  those  of  the  ovary  (Fig.  12(5),  and  it  is  ajiparently  y|^ 
the  largest  of  these  which  arc  most  apt  to  descend  into  the  pelvic  cavity^ 
AVhen  the  tumor  is  of  any  considerable  size,  its  bulk  is  such  that  it 
cannot  be  contained  in  the  true  pelvis,  and  it  rises  into  the  abdominal 

'  OhM.  Trans.,  1867.  vol.  ix.  p.  73.  "^  Ibid.  Jot  1877,  vol.  xix.  p.  101. 

*  This  procednre  is  objected  to  in  Di-.  John  Phillips'  paper,  already  quoted,  but  it 
seems  to  me  on  insufficient  grounds. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.         365 

cavity  with  the  uterus.     Hence,  the  existence  of  tlie  tumor  that  offers/ 
the  most  formidable  obstacle  to  delivery  is  rarely  suspected  before  labor  I 

sets  in. 

In  order  to  estimate  the  results  of  the  various  methods  of  treatment 
I  have  tabulated  57  cases.'  In  13,  lal)or  was  terminated  by  the  natural 
powers  alone,  but  of  these,  6  mothers,  or  nearly  one-half,  died,     la 

Fig.  J2G. 


Labor  complicated  by  Ovarian  Tumor. 


favorable  contrast  with  these  we  gave  the  cases  in  which  the  size  of  the 
tumor  was  diminished  by  puncture.     These  are  9  in  number,  in  all  of 
which  the  mother  recovered,  5  out  of  the  6  children  being  saved.    The 
reason  of  the  great  mortality  in  the  former  cases  is  apparently  the 
bruising  to  which  the  tumor,  even  when  small  enough  to  allow  the  child 
to  be  squeezed  past  it,  is  necessarily  subjected.     This  is  extremely  apt 
to  set  up  a  fatal  form  of  dii^use  inflammation,  the  risk  of  which  was 
long  ago  pointed  out  by  Ashwell,^  who  draws  a  comparison  between 
cases  in  which  such  tumors  have  been  subjected  to  contusion  and  cases 
of   strangulated  hernia;  and  the  cause  of  death  in  both  is  doubtless 
very  similar.     This  danger  is  avoided  when  the  tumor  is  punctured  so 
as  to  become  flattened  between  the  head  and  the  pelvic  walls.  (  On  this  I 
account  I  think  it  should  be  laid  down  as  a  rule  that  puncture  .should  / 
be  performed  in  all  cases  of  ovarian  tumor  engaged  in  front  of  the  \ 
presenting  part,  even  when  it  is  of  so  small  a  size  as  not  to  preclude  y 
the  possibility  of  delivery  by  the  natural  powers.N 

In  5  of  the  57  caseslit  was  found  possible  to  return_tlie  tumor  above 
the  pelvic  brim,  and  in  these  also  the  termination  was  very  fa\oral)le/ 
all  tlie  mothers  recovering.  Should  })uncture  not  succeed — and  it  may 
fail  on  account  of  the  gelatinous  and  semi-solid  nature  of  the  contents 
of  the  cyst — it  may  be  possible  to  dispose  of  the  tumor  in  this  way, 
1  ObM.  Trans.,  1867,  vol  ix.  p.  69.  '•*  Gwjs  Hospital  Reports,  vol.  ii. 


3()n  LMion. 

evc'ii  wIk'H  it  soeiiis  tu  he  Jiriiii\'  \v(»l;i,((l  dnwn   in  IVont  nl'  the  picscnt- 
iii^'  part  and  to  hi'  liopok'ssly  fixed   in   its  uni;iv(»raljle  potsitioji. 

(  Failing'  eitlier  oi"  those  resourees,  it  may  he  necessary  to  resort  to 
eraniotoniy.  ])rovided  the  size  of  the  tumor  prcchides  the  pctssihiiity  of 
delivery  hy  force  jit. 

[A  prohipsed  diTnioid  (yst  of  large  size  may  prove  such  an  obstacle 
as  to  recpiire  delivery  by  ahdoniinal  section.  I'his  has  hapjjened  hnt 
once  in  the  United  States,  the  cyst  containing  seventy  hours  after  the 
<»])eration  half  a  gallon  of  pus.  The  patient  Mas  oj)ei-ated  upon  hy  Dr. 
Ktheridgc  of  Chicago  on  Feb.  21,  1888,  and  dietl  in  eighty-two  lionrs. 
—El).] 

The  question  of  the  effect  on  labor  of  ovarian  tumor  -which  does  not 
obstruct  the  pelvic  canal  is  one  of  some  interest,  but  there  are  not  a 
sufficient  number  of  cases  recorded  to  throw  much  light  on  it.  I  am 
disposed  to  think  that  labor  generally  goes  ou  favorabi} .  AVhat  delay 
there  is  depeuds  on  the  mefficient  action  of  the  accessory  muscles 
engaged  in  parturition,  on  account  of  the  extreme  distension  of  the 
abdomen. 

There  are  a  few  other  conditions  connected  with  the  maternal  struc- 
tures which  may  impede  delivery,  but  Avhicli  are  of  comparatively  rare 
occurrence. 

Amongst  them  is  vaginal  cystocele,  consisting  of  a  prolapse  of 
the  distended  bladder  in  front  of  the  presentation,  where  it  forms  a 
tense  fluctuating  pouch  which  has  been  mistaken  ibr  a  hvdrocephalic 
luad  or  for  the  bag  of  membranes.'  This  complication  is  only  likely  to 
arise  when  the  bladder  has  been  allowed  to  become  unduly  distended 
from  want  of  attention  to  the  voiding  of  urine  during  labor.  '  The  diag- 
nosis should  not  offer  any  difficulty,  for  the  finger  will  be  able  to  pass 
behind,  but  not  .infmnt  of,  the  swelling,  and  reach  the  presenting  part, 
Avhile  the  pain  and  tenesmus  will  further  put  the  practitioner  un  his 
guard.  The  treatment  consists  in  cm])tving  the  l)la(lder,  but  there  may 
be  some  difficulty  in  passing  tTie  catheter,  in  conse(]uence  of  the  urethra 
being  dragged  out  of  its  natural  direction,  A  long  elastic  male  catheter 
will  almost  always  pass  if  used  with  care  and  gentleness.  Should  it  be 
found  impossible  to  draw  off  the  water — and  this  is  said  to  have  some- 
times happened — tlie  tense  ]wuch  might  be  punctured  without  danger 
bv  the  fine  needle  of  an  aspirator  trocar  and  its  contents  withdrawn. 
AVhen  once  the  viscus  is  emptied,  it  can  easily  be  pushed  above  the 
presenting  part  in  the  intervals  between  the  i)ains. 

In  some  few  cases  difficulties  have  arisen  from  the  existence  of  a 
vesical  calculus.  Should  this  be  pushed  down  in  front  of  the  head, 
it  can  readily  be  understood  that^the  maternal  structun'S  would  run  the 
risk  of  being  seriously  bruised  and  injured. \  Should  we  make  out  the 
existence  of  a  calculns — and  if  the  j)resence  of  one  be  suspected  the  diag- 
nosis could  easily  be  made  by  means  of  a  sound — an  endeavor  should 
be  made  to  pil&h  .iLi^Jil>ve,idie  J2rmi  of  the  pelvis.  '*If  that  be  found  to 
be  impossible,  no  resource  is  left  but  its  remcn-al,  either  by  cru§}iinp;  or 
bv  rapid  dilatation  of  the  urethra,  followed  by  I'xtraction.  Should  wei 
be  aware  of'tTTe^exferPirrcTTf'Ti  calculus  during  pi-egiiniuy,  its  removal] 
should  certainlv  l)e  nndertaken  before  labor  sets  in. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.  :M\1 

Hernial  protrusion  in  Douglas'  sjKur  may  sometimes  give  i-isc  to 
anxiety,  from  the  pressure  aiul  ('oiitu.sioii  to  wliicli  it  is  neeessarily  siih- 
jected.  xVn  endeavoi'  must  be  made  to  replace  it  and  to  modoa-ate  the 
straining  efforts  of  the  patient;  and  it  may  even  be  advisable  to  apply 
the  forceps  so  as  to  relieve  the  mass  from  pressure  as  soon  as  possible. 
It  is,  however,  ofjireat  rarity.  Fordyce  Barker,  in  an  interesting  paper 
on  the  subject,'  records  several  examples,  and  states  that  he  has  met  with 
no  instance  in  which  it  has  led  to  a  fatal  result,  either  to  mother  or 
child,  although  it  cannot  but  be  considered  a  serious  com])lication. 

Scybalous  masses  in  the  intestines  may  be  so  hard  and  impacted  { 
as  to  form  an  obstructionT'   The  necessity  of  attending  to  the  state  of  the  j 
rectum  has  already  been  pointed  out.     Should  it  be  found  impossible  to 
ompty  the   bowel   by   large  enemata,  the  mass  must  be  mechanically 
broken  down  and  removed  by  the  scoop. 

[Our  Southern  readers  are  aware  of  the  fact  that  their  lowest  class  of 
women  living  in  the  country  sometimes  eat  clay  as  a  remedy  for  heart- 
burn, and  occasionally  in  excessive  quantities,  during  the  pregnant 
state.  Impacted  clay  in  the  lower  bowels  has  on  two  occasions  proved 
such  an  obstacle  to  delivery  that  the  Csesarean  operation  Avas  performed, 
one  case  occurring  in  Louisiana  and  the  other  in  Georgia,  in  the  years 
.1866  and  1882  respectively,  after  labors  of  sixty  hours  and  three  days. 
The  first  case  recovered,  the  clay  being  removed  by  an  attack  of  diar- 
rhoea on  the  sixth  day.  The  second  died  of  convulsions  in  twenty  days 
after  the  uterine  and  abdominal  wounds  had  healed.  Under  chloro- 
form about  two  and  a  half  pounds  of  sand  and  marl  were  removed 
three  days  after  the  operation. — Ed.] 

Excessive  oedejnatQ13^_  infiltration  may  sometimes 

cause  obstruction,  and  require  diminution  in  size,  which  can  easily  be 
effected  by  numerous  small  punctures. 

/  Hsematic  effusions  into  the  cellular  tissue  of  the  vulva  or  vagina 
form  a  grave  complication  of  labor.N  Such  blood-swellings  are  most 
usually  met  with  in  one  or  both  labia  or  under  the  vaginal  wall ;  in  the 
gravest  forms  the  blood  may  extend  into  the  tissues  for  a  considerable 
distance,  as  in  the  case  recorded  by  Cazeaux,  where  it  reached  upward 
as  far  as  the  umbilicus  in  front  and  as  far  as  the  attachment  of  the 
diaphragm  behind. 

The  conditions  associated  with  pregnancy,  the  distension  and  engorge- 
ment to  which  the  vessels  are  subjected,  the  interference  with  the  return 
of  the  blood  by  the  pressure  of  the  head  during  labor,  and  the  violent 
efforts  of  the  patient,  aflPorcl  a  ready  ex])lanation  of  the  reason  why  a  ves- 
sel may  be  predisposed  to  rupture  and  admit  of  the  extravasation  of 
blood. 

The  accident  is  fortunately  for  from  a  common  one,  although  a  suf- 
ficient number  of  cases  are  recorded  to  make  us  familiar  with  its  symp- 
toms and  risks.  The  dangers  attending  such  effusions  would  seem  to 
be  great  if  the  statistics  given  by  those  who  have  written  on  the  subject 
are  to  be  trusted.  Thus,  out  of  124  cases  collected  by  various  French 
authors,  44  proved  fatal.  Fordyce  Barker  points  out  that  since  the 
nature  and  a])pro]iriate  treatment  of  the  accident  have  been  more  thor- 

'  Anur.  Journ.  of  Obat.,  1876,  yu\.  ix.  p.  177. 


3()H  LABOR. 

<tii<j;lily  iiiidcrstudd  (lie  iiiortMlity  liiis  lui-n  iiiiicli  Nssriicd,  loi- (»iit  of"  lo 
cases  ivpoitcd  hy  S-.mzoiii,  only  1  died,  and  out  of  22  wises  Ik- had  liirii- 
self'seeii,  2  died  ;  and  all  these  three  deaths  were  from  puerperal  fever, 
and  not  the  direct  result  of  the  accident.' 

(The  blo(Kl  inav  be  effused  into  any  part  of  the  ]Kl\ic  cellular  tissue 
or  into  the  lahiaj  The  accident  most  often  ha]>j)cns  during  labor  when 
the  liead  is  low  down  in  the  pelvis,  not  nnfrc(picntly  just  as  it  is  al)OUt 
to  escai)e  from  the  vulva,  liciice  the  extravasation  is  more  often  met 
with  low  down  in  the  vagina,  and  more  frequently  in  one  of  the  hibia 
than  in  any  other  situation.  I  have  met  with  a  case  in  which  I  liad 
every  reason  to  believe  that  an  extravasation  of  i)lood  had  occurred 
within  the  tissues  immediately  surrounding  the  cervix.  It  is  natural  t(» 
su])pose  that  a  varicose  condition  of  the  veins  about  the  vulva  wouhl 
predispose  to  the  accident,  but  in  most  of  the  recorded  examples  this  is 
not  stated  to  liave  been  the  case.  Still,  if  varicose  veins  exist  to  any 
marked  degree,  some  anxiety  on  this  point  cannot  but  be  felt. 

The  thrombus  occasionally,  though  rarely,  forms  before  delivery. 
Most  commonly  it  first  forms  toward  the  end  of  labor  or  after  the  birth 
of  the  child.  In  the  latter  case  it  is  probable  that  the  laceration  in  the 
vessels  occurred  before  the  birth  of  the  child,  and  that  the  j)ressure  of 
the  presenting  part  prevented  the  escape  of  any  quantity  of  blood  at  the 
time  of  laceration. 

The  syraptoras  are  not  by  any  meanscharacteristic.  Pain  of  a 
tearing  character,  occasionally  very  intense,  and  exteiKling  toTRe  back 
aiKLdoxviLtJie,  thighs,  is  very  generaTly  associated  with  the  formaFion  of 
the  thrombus.  If  a  careful  physical  examination  be  made  the  nature  of 
the  case  can  readily  be  detected.  (When  the  blood  escapes  into  the 
labium,  a  firm,  hard  swelling  is  felt,  which  has  even  been  mistaken  for 
the  foetal  head.  .  If  the  effusion  implicate  the  internal  parts  only,  the 
diagnosis  may  not  at  first  be  so  evident.  But  even  then  a  little  care 
sliovdd  prevent  any  mistake,  for  the  swelling  may  be  felt  in  the  vagina, 
and  may  even  form  an  obstacle  to  the  passage  of  the  diild.  C'azeaux 
mentions  cases  in  which  it  was  so  extensive  as  to  compress  the  rectum 
and  urethra,  and  even  to  prevent  the  exit  of  the  lochia.  ^In  some  cases 
the  distension  of  the  tissues  is  so  great  that  thcA-  lacerate,  and  then  hem- 
ori-hage,  sometimes  so  profuse  as  directly  to  imperil  the  life  of  the 
])atient,  may  occur.  \The  bursting  of  the  skin  may  take  place  some  time 
subsequent  to  the  formation  of  the  thrombus.  Constitutional  symptoms 
will  be  in  proportion  to  the  amount  of  blood  lost,  either  by  extravasa- 
tion or  externally,  after  the  rupture  of  the  superficial  tissues.  Occasion- 
ally they  are  considerable,  and  are  the  same  as  those  of  hemorrhage 
from  any  cause. 

Tiie  termination  of  thromlius  is  either  sjiontaneous  absorption,  M"hich 
may  occur  if  the  amount  of  blood  extravasated  be  small  ;  or  the  tumor 
may  burst,  and  then  there  is  external  hemorrhage  ;  or  it  may  supjmrate, 
the  contained  coagula  being  discharged  from  the  cavity  of  the  cyst;  or, 
finally,  sloughing  of  the  supei-ficial  tissues  has  occurred. 

The  treatment  must  nattu-ally  vary  with  the  size  of  the  throml)Us 
and  the  time  at  which  it  forms.     If  it  be  met  with  during  labor,  unless 

'  Thr  Puerperal  Dkenses,  j).  60. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.         369 

it  be  extremely  small,  it  will  be  very  apt  to  form  an  obstruction  to  the 
j)assaj2;e  of"  the  child.  Under  such  circumstances  it  is  clearly  advisable 
•to  terminate  the  labor  as  soon  as  possible,  so  as  to  remove  the  obstacle 
to  the  circulation  in  the  vessels.  (For  this  purpose  the  force })s  should 
be  applied  as  soon  as  the  head  can  be  easily  reached .1  If  the  tumor 
itself  obstruct  the  })assage  of  the  head  or  if  it  be  of  any  consideral)le  size, 
it  will  be  necessary  to  incise  itii'eelv  at  its  most  prominent  point  and 
turn  out  the  coagula,  controlling  the  hemori'hage  at  once  by  filling  the 
cavity  with  cotton  wadding  saturated  in  a  solution  of  perchloride  of 
iron,  while  at  the  same  time  digital  compression  with  the  tips  of  the  fin- 
gers is  kept  up.  By  this  means  pressure  is  applied  directly  to  the 
bleeding  point,  and  the  hemorrhage  can  be  controlled  without  difficulty. 
This  is  all  the  more  necessary  if  spontaneous  rupture  have  taken  place, 
for  then  the  loss  of  blood  is  often  profuse,  and  it  is  of  the  utmost 
importance  to  reach  the  site  of  the  hemorrhage  as  early  as  possible. 

IJf  the  thrombus  be  not  so  large  as  to  obstruct  delivery,  or  if  it  be  not 
detected  until  after  the  birth  of  the  child,  the  question  arises  whether 
the  case  should  not  be  left  alone,  in  the  hope  that  absorption  may 
occur,  as  in  most  cases  of  jjelvic  haematocele.  )  This  expectant  treatment 
is  advised  by  Cazeaux,  and  it  seems  to  be  the  most  rational  plan  we 
can  adopt.  True,  it  may  take  a  longer  time  for  the  patient  to  conva- 
lesce completely  than  if  the  coagula  were  removed  at  once  and  the  hem- 
orrhage restrained  by  pressure  on  the  bleeding  point ;  but  this  disad- 
vantage is  more  than  counterbalanced  by  the  absence  of  risk  from 
hemorrhage,  and  of  septicsemia  from  the  suppuration  that  must  neces- 
sarily follow,  i  Softening  and  suppuration  may  in  many  cases  occur  in 
a  few  days,  necessitating  operation,  but  the  vessels  will  then  be  probably 
occluded  and  the  risk  of  hemorrhage  much  lessened)  Dr.  Fordyce 
Barker,  however,  holds  the  opposite  opinion,  and  thinks  that  the  proper 
plan  is  to  open  the  thrombus  only,  controlling  the  hemorrhage  in  the 
manner  already  indicated,  unless  the  thrombus  is  situated  high  in  the 
vaginal  canal. 

Whenever  the  cavity  of  a  thrombus  has  been  opened,  either  by  incision  ' , 
or  by  spontaneous  softening  at  some  time  subsequent  to  its  formation,  it  ^ 
must  not  be  forgotten  that  there  is  considerable  risk  of  septic  absorp-  / 
tion.     To  avoid  this,  care  must  be  taken  to  use  antiseptic  dressings 
freely,  such  as  iodoform  powder  or  avooI,  applied  directly  to  the  part, 
and  frequent  vaginal  injections  of  diluted  Condy's  fluid.     Barker  lays  i 
special  stress  on  the  importance  of  not  removing  prematurely  the  coagula  I 
formed  by  the  styptic  applications,  for  fear  of  secondary  hemorrhage,  but 
of  allowing  them  to  come  away  spontaneously. 

[Polypus. — Large  uterine  polypi  may  act  as  serious  obstacles  to 
deliviSiT.  When  sufficiently  long  in  pedicle,  a  polypus  may  be  ex- 
truded before  the  head  of  the  ftetus.  The  tumor  may  also  be  detached 
in  its  expulsion,  or  may  be  removed  by  an  ecraseur  if  recognized  in 
time:  it  may  also  be  pushed  up  out  of  the  way  and  secured  by  bringing 
down  the  child.  I  once  rejjlaced  a  large  polypus  that  was  extruded  before 
the  head,  and  the  woman  carried  it  two  years  longer ;  by  which  time, 
being  much  wasted  by  the  discharge,  she  made  up  her  mind  to  have  it 
removed. — Ed.] 

24  ^-> 


370 


LABOR. 


A 


d 


CHAPTER   XI. 

DIFFKTLT    LABOR   DEPENDING    ON    SOME    UNUSUAL    CONDITION 

OF  THE   FCETUS. 

Plural  Births. — The  subject  of  multiple  pregnancy  in  general  having 
already  been  fully  considered,  we  have  now  only  to  discu.ss  its  practit-al 
bearing  as  regards  labor.  Fortunately,  the  existence  of  twins  rarely 
gives  rise  to  any  serious  difficulty.  Tin  the  large  proportion  of  cases  the 
presence  of  a  second  foetus  is  not  suspected  until  the  birth  of  the  fii-st, 
when  the  nature  of  the  case  is  at  once  apparent  from  the  fact  of  the 
uterus  remaining  as  large,  or  nearly  as  large,  as  it  was  before.) 

There  may  possil)ly  be  some  delay  in  the  birth  of  the  fir-^t  child,  inas- 
luuch  as  the  extreme  distension  of  the  uterus  mav  interfere  with  'it$ 


thoroughly  efficient  action; (while,  in  addition,  the  uterine 

^  directly  conveyed  to  the  ov 


Fig.  127. 


g  ])ressure  is  notjj    M 
um  as  in  single  \     n 


births,  but  indirectly  throngh  the  anniintic  [' 
sac  of  the  second  child  (Fig.  127).)  Such^ 
delay  is  especially  apt  to  arise  \\i\en  the 
first  child  presents  by  the  breech,  for  even 
if  the  body  be  expelled  spontaneously, 
difficulty  is  likely  to  occnr  M'ith  the  head, 
since  the  uterus  does  not  contract  upon  it, 
as  is  ordinarily  the  case.  Hence,  tiie  in- 
tervention of  the  accoucheur  to  save  the 
life  of  the  child  by  the  extraction  of  the 
head  will  be  almost  a  matter  of  necessity. 
In  the  majority  of  eases,  after  the  birth 
of  the  first  child  there  is  a  temporary  lull 
in  the  pains,  which  soon  recommence, 
generally  in  from  ten  to  twenty  minutes, 
and  the  second  child  is  rapidly  expelled, 
for  on  account  of  the  fujl  dilatation  of  the 
soft  parts  there  is  no  obstacle  to  its  delivery^ 
Sometimes  there  is  a  considerable  interval 
Twin  Prcgnamy,  BrlcIi  and  Head  before  the  pains  rccur,  and   instances  are 

Presenting.  i     i       •  i  •   i  11 

recorded     in    which    even    several    clays 
elapsed  between  the  births  of  the  two  children. 

Treatment. — In  most  cases  the  management  of  twins  does  not  ditt'er 
from  that  of  ordinary  labor.  As  soon  as  we  are  certain  of  the  existence 
of  a  second  IVi'tn.s  we  should  inform  the  bystanders,  but  not  necessarily 
the  mother,  to  whom  the  news  might  ])rove  an  luiplcasant  and  even 
dangerous  shock.  Then,  having  taken  care  to  tie  the  cord  of  the  first 
child  for  fear  of  vascular  comnumication  between  tlie  plac-enta?,  our  duty 
is  to  wait  for  a  recurrence  of  the  pains.     If  these  come  on  i*apidly  and 


DYSTOCIA   FROM  FCETUS.  371 

the  presentation  of  tlie  second  foetus  be  normal,  its  birth  is  managed  in 
the  usual  way. 

If  there  be  any  unusual  delay  we  have  to  consider  the  ])roper. course 
to  pursue,  and  on  this  the  opinions  of  authorities  differ  greatly, '  Some 
advise  a  delay  of  several  hours,  and  even  more,  if  pains  do  not  recur 
s})ontaueously ;  while  others — Murphy,  for  example — recommend  that 
the  second  child  should  be  delivered  at  once.  ^Either  extreme  of  prac- 
tice is  probably  wrong,  and  the  safest  and  best  course  is  doubtless  the 
medium  one.  The  second  point  to  bear  in  mind  is,  that  in  multiple 
pregnancy,  on  account  of  the  extreme  distension  of  the  uterus,  there  is 
a  tendency  to  inertia,  and  consequently  to  post-partum  hemorrhage, 
and  that,  therefore,  it  is  better  that  the  birth  of  the  second  child  should 
be  delayed,  even  for  a  considerable  time,  rather  than  that  the  patient 
should  run  the  risk  attending  an  empty  and  uncontracted  uterus.  If, 
however,  uterine  action  be  present,  there  is  an  obvious  advantage  in  the 
delivery  of  the  second  child  before  the  dilatation  of  the  passages  passes 
off. 

The  best  plan  would  seem  to  be  if,  after  waiting  a  quarter  of  an  hour, 
Jabor-pains  do  not  occur,  to  try  and  induce  them  by  uterine  friction  and 
pressure  and  by  the  administration  of  a  dose  of  ergot,  to  which,  as  there 
can  be  no  obstacle  to  the  rapid  birth  or~tlie  second  child,  there  can  be 
now  no  objection.  [(The  membranes  of  the  second  child  should  alwaysl 
be  ruptured  at  onc^  if  easily  within  reach,  as  one  of  the  speediest  means\ 
of  inducing  contraction.^  If  no  progress  be  made  and  speedy  delivery 
be  indicated — a  necessity  which  may  arise  either  from  the  exhausted 
state  of  the  patient,  the  presence  of  hemorrhage,  extremely  feeble  pul- 
sations of  the  foetal  heart  (showing  that  the  life  of  the  second  child  is 
endangered),  or  malpresentations  of  the  second  foetus — turning  is  prob- 
ably the  readiest  and  safest  expedient.  Under  such  circumstances  the 
operation  is  performed  with  great  ease,  since  the  passages  are  amply 
dilated.  After  bringing  down  the  feet  the  birth  of  the  body  should  be 
sloMdy  effected,  with  the  view  of  ensuring  as  complete  subsequent  con- 
traction as  possible.  ',  If  the  head  has  descended  in  the  pelvis,  of  course 
turning  is  impossible  and  the  forceps  must  be  applied) 

DiflB,culties  arising  from  Locked  Twins. — Occasionally  very  seri-  ' 
ous  difficulties  arise  from  parts  of  both  foetuses  presenting  simultane- 
ously, and  thus  impeding  the  entrance  of  either  child  into  the  pelvis, 
or  getting  locked  together,  so  as  to  render  delivery  impossible  without 
artificial  aid.  Such  difficulties  are  not  apt  to  arise  in  the  more  ordinary 
cases,  in  which  each  child  has  its  own  bag  of  membranes,  since  then  the 
foetuses  are  kept  entirely  separate,(but  in  those  in  which  the  twins  are 
contained  in  a  common  amniotic  cavity  or  in  which  both  sacs  have  burst 
simultaneously.'  They  are  very  puzzling  to  the  obstetrician,  and  it  may 
be  far  from  easy  to  discover  the  cause  of  the  obstruction.  Nor  is  it  pos- 
sible to  lay  down  any  positive  rules  for  their  management,  which  must 
be  governed  to  a  considerable  extent  by  the  circumstances  of  each  indi- 
vidual case. 

Sometimes  both  heads  present  simultaneously  at  the  brim,  and  then 
neither  can  enfer  unless  they  be  unusually  small  or  the  pelvis  very 
capacious,  when  both  may  descend ;  or  rather  the  first  head  may  descend 


372  LABOR. 

low  into  the  pelvic  cavity,  and  then  the  second  head  enters  the  brim  and 
get.«  Janiined  against  the  thorax  of  the  first  child  (Fig.  128).  Reiniann' 
relates  a  curious;  example  of  this  iu  which  he  delivered  the  head  first 

Fio.  128. 


Shows  Head-locking,  both  children  presenting  head  first.    (After  Barnes.) 

•with  the  forceps,  but  found  the  body  M-^ould  not  follow,  and  on  exami- 
nation a  second  head  was  found  in  the  pelvis.    He  then  applied  the  for- 
ceps to  the  second  head;  the  body  of  the  first  child  Mas  then  born,  and 
afterward  that  of  the  second.     Such  a  mechanism  must  clearly  have  been 
impossible  unless  the  pelvis  had  been  extremely  large. 
.      Whenever  both  heads  are  felt  at  the  brim  it  will  generally  be  found 
]  possible  to  get  one  out  of  the  way  by  appropriate  manipulation,  one 
'  hand  being  passed  into  the  vagina,  the  other  aiding  its  action  from 
Avithout.     Then  the  forceps  may  be  applied  to  the  other  head,  so  as  to 
engage  it  at  once  in  the  pelvic  cavity.     If  both  have  actually  jxissed 
into  the  pelvi.s,  as  in  the  case  ju.st  alluded  to,  the  difficulty  will  be  much 
greater.    (It  will  generally  be  easier  to  jnish  up  the  second  head,  while 
the  lower  is  drawn  out  by  the  forceps,  than  to  deliver  the  second,  leav- 
ing the  first  in  situ.   ' 

In  other  cases  a  foot  or  hand  may  descend  along  withjihe  head,  and 
even  the  four  feet  iiiay  present  simultaneously.  Tiie  rule  iuTlie  former 
case  is  to  push  the  part  descending  with  the  head  out  of  the  way,  and 
in  the  latter  to  disengage  one  child  as  soon  as  possible.  Great  care  is 
necessaiy,  or  we  might  possibly  bring  down  the  limbs  of  separate 
children. 

V.  The  most  common  kind  of  difficulty  is  when  the  fii-st  child  presents 
by  the  breech,  and  is  delivered  as  far  as  the  head,  which  is  then  found 

»  Arch.  f.  Gyndk.,  1871,  Bd.  ii.  p.  99. 


DYSTOCIA  FROM  FCETUS. 


373 


to  be  locked  with  the  head  of  the  second  cliild,  which  has  descended 
into  the  pelvic  cavity  (Fig.  129).  i 

Here  it  is  clear  that  the  obstruction  must  be  very  great,  and,  unless 
the  children  are  extremely  small,  insuperable.  The  first  endeavor 
should  be  to  disentangle  the  heads:  this  is  sometimes  feasible  if  the 
second  be  not  deeply  engaged' in  the  pelvis  and  the  hand  be  passed  up 

Fig.  129. 


Shows  Head-locking,  first  child  coming  feet  fir.st ;  impaction  of  heads  from  wedging 

in  brim.    (After  Barnes.) 

D.  Apex  of  wedge,    e,  c.  Base  of  wedge,  which  cannot  enter  brim,    a,  b.  Line  of  decapitation  to  decompose 

wedge  and  enable  head  of  second  child  to  pass. 

SO  as  to  push  it  out  of  the  way.  This  will  but  rarely  succeed  -jl^  then  it 
may  be  possible  to  apply  the  forceps  to  the  second  head  and  drag  it  past 
the  body  of  the  first  child  i  and  this  is  the  method  recommended  by 
Reimann,  who  has  written  an  excellent  paper  on  the  subject.^  ^Gen- 
erally, the  sacrifice  of  one  of  the  children  is  essential,  and  as  the  body 
of  the  first  cTiild  must  have  been  born  for  some  time,  it  is  probable 
that  the  pressure  to  which  it  has  been  subjected  will  have  already 

'  American  Journal  of  Obstetrics,  1877,  vol.  x.  p.  47. 


374  LABOR. 

iiiijH'rilK'd,  if  it  h;is  not  dt'stroyt'd,  its  life,  and  tlicrclnrc  tlic  |)laM 
usually  reconuuouded  is  to  docapitato.  This  can  easily  be  done  witli 
scissors  or  a  wire  ccraseur,  after  which  the  second  child  is  expelled 
■without  difiiculty,  leaving  the  head  of  the  first  in  utcro  to  be  subse- 
quently dealt  Avith.") 

AnotluT  mode  of  nuuiai2;int>;  these  cases  is  to  perforate  the  u|)pcr  head 
anil  draw  it  past  the  lower  with  the  cephalotribe  or  craniotomy  forc('])s. 
This  })lan  has  the  disadvantage  of  probably  sacrificing  both  children, 
since  the  other  child  can  hardly  survive  the  pressure  and  delay  ;  where- 
as the  former  plan  gives  the  second  child  a  fair  chance  of  being  born 
alive. 

Double  Monsters. — In  connection  with  the  snl)ject  of  twin  labor 
we  may  consider  those  rare  cases  in  which  the  bodies  of  the  fietuses 
are  partially  fused  together.  The  mechanism  and  management  of 
delivery  in  cases  of  double  monstrosity  have  attracted  comparatively 
little  attention,  no  doubt  because  authors  have  considered  them  matters 
of  curiosity  merely,  rather  than  of  practical  importance. 

The  frequent  occurrence  of  such  monstrosities  in  our  museums,  and 
the  numerous  cases  scattered  through  our  })eriodical  literature,  are  suf- 
ficient to  show  that  they  are  not  so  very  rare  as  we  might  be  inclined 
to  imagine;  and,  as  they  are  likely  to  give  rise  to  formidable  difficul- 
ties in  delivery,  it  cannot  be  unimjiortant  to  have  a  clear  idea  of  the 
usual  course  taken  by  nature  in  effecting  such  births,  with  a  view  of 
enabling  us  to  assist  in  the  most  satisfactory  manner  should  a  similar 
case  come  under  our  observation. 

Unfortunately,  the  authors  Avho  have  placed  on  record  the  birth  of 
double  monsters  liave  generally  occupied  themselves  more  with  a  descrip- 
tion of  the  structural  peculiarities  of  the  foetuses  thau  with  the  mechan- 
ism of  tlieir  delivery ;  so  that,  although  the  eases  to  be  met  with  in 
medical  literature  are  very  numerous,  comparatively  few  of  them  are 
of  real  value  from  an  obstetric  point  of  view.  Still,  I  have  been  able 
to  collect  the  details  of  a  considerable  number*  in  which  the  history  of 
the  labor  is  more  or  less  accurately  described ;  and  doubtless  a  more 
extensive  research  would  increase  the  list. 

Double  Monstrosity  may  be  Divided  into  Four  Classes. — For 
obstetric  purposes  we  may  confine  our  attention  to  ibur  jirineipal  varie- 
ties of  double  monstrosity  which  are  met  with  far  more  frequently  than 
any  others.     These  are : 

A.  Two  nearly  .separate  bodies  united  in  front,  to  a  varying  extent, 
by  thorax  or  abdomen. 

B.  Two  nearly  separate  bodies  united  back  to  back  by  the  sacrum 
and  lower  part  of  the  spinal  column. 

C.  Dice]>halous  monsters,  the  bodies  being  single  below,  but  the 
heads  separate. 

D.  The  bodies  separate  below,  but  the  heads  partially  united. 

This  classification  by  no  means  includes  all  the  varieties  of  monstei'S 
that  we  meet  with.  It  does,  however,  include  all  that  are  likely  to  give 
rise  to  much  difficulty  in  delivery;  and  all  the  cases  I  have  collected 
may  be  placed  under  one  of  these  divisions. 

'  OOxt.  Tran^.,  1867,  vol.  viii.  p.  300. 


DYSTOCIA   FROM  FCETUS.  375 

The  first  point  that  strikes  us  in  looking  over  the  history  of  these 
deliveries  is  the  frequency  with  which  they  have  lx*n  terniinate<^I  liv 
tiie  natural  powei-s  alone,  without  any  assistance  on  the  part  of  the 
acc-ouchcur.  Thus,  out  of  the  31  cases,  no  Ic^s  than  20  were  deliven-d 
naturallv,  and  apparently  without  much  trouble.  Nothing  can  better 
show  the  wonderful  resoiu*ces  of  nature  in  overc-oming  difficulties  of  a 
verv  fnrmidable  kind. 

it  is  })rettv  generally  assumed  by  authors  that  the  children  are  neces- 
sarilv  premature,  and  therefore  of  small  size,  and  that  delivery  before 
the  full  term  is  rather  the  rule  than  the  exception.  Duges  states  that 
the  children  are  often  dead,  and  that  putrefaction  has  taken  place, 
which  facilitates  their  expulsion.  Both  these  assumptions  seem  to  me 
to  have  Ijeen  made  without  sufficient  authority,  and  not  to  be  borne  out 
bv  the  recorded  facts.  In  only  1  of  the  31  cases  it  is  mentioned  that 
the  children  were  premature:  nor  is  there  any  sufficient  rea.son  that  I 
can  see  why  labor  should  commence  before  the  full  term  of  gestation. 

Class  A. — By  far  the  greatest  number  are  included  in  the  first  class 
— that  in  which  the  bodies  are  nearly  separate,  but  united  by  some  part 
of  the  thorax  or  alxlomen.  This  is  the  diWsion  which  includes  the 
celebrate*:!  Siamese  Twins,  an  account  of  whose  birth,  I  may  observe, 
I  have  not  l)een  able  to  discover.^  /Out  of  the  31  c-ases,  19  come  under 
this  heading.  The  details  of  the  labors  are  briefly  as  follows:  1  died 
undelivered  ;  8  were  terminated  by  the  natural  powers,  in  3  of  which 
the  feet,  and  in  3  the  head,  presented ;  in  2  the  presentation  is  doubt- 
ful ;  6  were  delivered  by  turning  or  by  traction  on  tiie  lower  extremi- 
ties ;  4  were  delivered   instrumentally. 

The  details  of  the  cases  in  which  the  feet  presented  or  in  ^shieh  turn- 
ing was  performed  clearly  show  that  footling  pr^ntation  was  by  far 
the  most  favorable;  and  it  is  fortunate  that  the  feet  often  present 
naturally.  The  inference  of  course  is  that  version  should  be  resorted 
to  whenever  any  other  presentation  is  met  with  in  cases  of  double  mon- 
strosity of  this  type :  but,  unfortunately,  this  rule  could  rarely  be 
carried  into  execution,  since  we  possess  no  means  of  diagnosing  the 
junction  of  the  fcetases  at  a  sufficiently  early  stage  of  lalx»r  to  admit 
of  tiu^ning  being  performed.  It  is  only  under  exceptionally  favorable 
circumstances  that  this  can  be  done ;  as,  for  example,  in  a  case  recorded 
by  Molas,  in  wliich  both  heads  presented,  but  neither  would  enter  the 
brim  of  the  pelvis. 

The  great  difficidty  mtist,  of  course,  be  in  the  delivery  of  the  heads, 
f  jr  in  all  the  recorded  cases,  with  one  exception,  the  Ixxlies  have  passed 
through  the  pelvis  parallel  to  each  other  with  comparative  ease  imtil 
the  necks  have  appeared,  and  then,  as  a  rule,  they  could  be  brought  no 

['  The  mother  of  these  twins  was  once  seen  by  Dr.  Ruschenbei^r  of  Philadelphia 
at  Bangkok :  she  was  a  Chinese  half-breed,  short,  and  with  a  broad  pelvis,  and  had 
borne  several  children  previously.  She  stated  on  several  occasions,  in  conversation 
with  parties  in  Siam.  that  the  twins  were  bom  reversed,  the  feet  of  one  being  followed 
by  the  head  of  the  other,  and  that  they  were  very  small  and  feeble  at  binh  and  for 
several  months  afterward.  The  twins  confirmed  this  statement  by  affirming  that  they 
could,  when  little  boys  at  play  on  the  ground,  turn  themselves  end  for  end  upon  the 
ensiform  attachment  up  to  the  age  of  ten  or  twelve,  the  attachment  being  then  soft 
and  pliable.    Although  called  Siamese,  they  were  three-quarters  Chinese. — Ed.] 


37()  LABOR. 

farther.  It  is  clear  that  the  rcinaiiidcr  of  tho  foetuses  could  no  longer 
pass  sinniltanoonsly,  and  were  direct  traction  continued  the  heads  would 
be  inextricably  fixed  above  the  brini.'^  In  accordance  with  the  direction 
of  the  pelvic  axes  the  posterior  head  must  first  engage  iu  tlie  inlet ;  and 
in  order  to  effect  this  it  will  be  necessary  to  carry  the  bodies  of  the 
children  well  over  the  abdomen  of  the  mother.)  This  seems  to  be  a 
point  of  primary  importance.  ;  It  Avould  also  be  advisable  to  see  tiiat 
the  bo<lies  are  made  to  pass  through  the  pelvis  with  their  backs  in  the 
oblic[ue  diameter,  j  By  this  means  more  space  is  gained  than  if  the 
backs  were  placed  antero-posteriorly,  while  at  the  same  time  there  is 
less  chance  of  the  heads  hitching  against  the  promontory  of  the  sacrum 
and  symphysis  j)ubis,  which  otherwise  would  be  very  apt  to  occur. 

M'hcn  the  head  presents  and  the  labor  is  terminated  by  the  natural 
powers,  delivery  seems  to  be  accomplished  in  one  of  two  ways: 

In  the  first  and  more  common  the  head  and  shoulders  of  one  child 
are  born,  its  breech  and  legs  being  subsequently  pushed  through  the 
pelvis  by  a  process  similar  to  that  of  spontaneous  evolution ;  and  after- 
ward the  second  child  probably  passes  footling  without  much  difficulty, 

Barkow  relates  a  case  in  which  both  heads  were  delivered  by  the  for- 
ceps, the  bodies  subsequently  passing  simultaneously.  Two  similar 
instances  are  recorded  in  the  third  and  sixth  volumes  of  the  Obstetrical 
Transact  ions.  When  delivery  takes  place  in  this  manner  the  head  of 
the  second  child  must  fit  into  the  cavity  formed  by  the  neck  of  the  first, 
and  tlie  pelvis  must  necessarily  be  sufficiently  roomy  to  admit  of  the 
expulsion  of  the  head  of  the  second  child,  while  its  cavity  is  dimin- 
ished in  size  by  the  presence  of  the  neck  and  shoulders  of  the  first. 
Either  of  these  processes  must  obviously  require  exceptionally  favor- 
able conditions  as  regards  the  size  of  the  child  and  the  pelvis,  and  the 
difficulty  in  the  way  of  delivery  must  be  much  greater  than  when  the 
lower  extremities  present.  1^ Therefore  I  think  the  rule  should  be  laid 
down  that  when  the  nature  of  the  case  is  made  out  (and  for  the  pur- 
pose of  accurate  diagnosis  a  complete  examination  under  anaesthesia 
should  be  practised)  turning  should  be  performed  and  the  feet  brought 
down. ) 

In  the  event  of  its  being  found  impossible  to  effi?ct  delivery  after  a 
considerable  portion  of  the  bodies  is  born,  no  resource  remains  but 
the  mutilation  of  the  body  of  one  child,  so  as  to  admit  of  the  passage 
of  the  other.  This  was  found  necessary  in  one  case  in  which  the 
children  presented  by  the  feet  and  were  born  as  far  as  the  thorax,  but 
could  get  no  farther.  The  body  of  the  anterior  child  was  removed 
by  a  circular  incision  as  far  as  it  had  been  expelled,  Avhich  allowed  the 
remaining  portion,  consisting  of  the  head  and  shoulders,  to  re-enter  the 
uterus ;  after  this  the  ])osterior  child  was  easily  extracted,  and  the 
mutilated  fretus  followed   without  difficulty. 

Class  B. — In  Class  B,  in  M'hich  the  children  are  united  back  to  back, 
3_ .cases  are  recorded,  all  of  which  were  delivered  by  the  natural  powers. 
One  of  these  is  the  case  of  Judith  and  Helene,  the  celebrated  Hun- 
garian twins,  who  lived  to  the  age  of  twenty-one.  Helene  was  l)orn 
as  far  as  the  umbilicus,  and  after  the  lapse  of  three  hours  her  breech 
and  legs  descended.     Judith  w^as  expelled  immediately  afterward,  her 


DYSTOCIA  FROM  FCETUS.  377 

feet  descending  first. [']  Exactly  the  same  process  occurred  in  a  case 
described  by  M.  Norman,  the  children  being  also  born  alive,  and 
dying  on  the  ninth  day. 

It  is  probable  that  labor  is  easier  in  this  case  of  double  monsters  than 
in  the  former,  because  the  children  are  so  joined  that  there  is  no  neces- 
sity for  the  bodies  to  be  parallel  to  each  other  during  birth  when  the 
head  presents,  and  after  the  birth  of  the  head  and  shoulders  of  the  first 
child  its  breech  and  lower  extremities  are  evidently  pushed  down  and 
expelled  by  a  process  of  spontaneous  evolution.  If  the  feet  originally 
presented,  the  mechanism  of  delivery  and  the  rules  to  be  followed 
would  be  the  same  as  in  Class  A;  but  the  difficulty  would  probably 
be  greater,  since  the  juncture  is  not  so  flexible,  and  a  more  complete 
parallelism  of  the  bodies  would  be  necessary  during  extraction. 

Class  C. — In  Class  C,  that  of  the  dicephalous  monster,  I  have  found 
the  description  of  the  birth  of  8  cases,  3  of  which  were  terminated  by 
the  natural  powers.  In  2  of  these  cases  the  process  of  evolution  was 
the  main  agent  in  delivery,  one  head  being  born  and  becoming  fixed 
under  the  arch  of  the  pubes,  the  body  being  subsequently  pushed  past 
it,  and  the  second  head  following  without  difficulty.  This  process  fail- 
ing, the  proper  course  is  to  decapitate  the  first-born  head,  and  then 
bring  down  the  feet  of  the  chilH7wheu  delivery  can  be  accomplished 
with  ease.  This  was  the  course  adopted  in  2  out  of  the  8  cases ;  and 
it  may  be  done  with  the  less  hesitation  since,  from  their  structural 
peculiarities,  (it  is  extremely  improbable  that  monsters  of  this  kind 
should  survive.)  In  the  third  case,  terminated  naturally,  the  heads 
were  said  to  have  been  born  simultaneously,  but  it  seems  probable  that 
the  one  head  lay  in  the  hollow  formed  by  the  neck  of  the  other,  and  so 
rapidly  followed  it.  If  the  feet  presented,  the  case  may  be  managed 
in  the  same  manner  as  in  Class  A. 

Class  D. — Monstrosities  of  Class  D,  in  which  the  heads  are  united, 
the  bodies  being  distinct,  appear  to  be  the  most  uncommon  of  all,  and 
I  can  find  the  description  of  delivery  in  only  2  cases.  One  of  these 
gave  rise  to  great  difficulty;  the  labor  in  the  other  was  easy.  We 
should  scarcely  anticipate  much  difficulty  in  the  birth  of  monsters  of 
this  type ;  for  if  the  head  presented  and  would  not  pass,  we  should 
naturally  perform  craniotomy;  and  if  the  bodies  came  first,  the  delivery 
of  the  monstrous  head  could  readily  be  accomplished  by  perforation. 

The  result  to  the  mothers  in  all  these  cases  seems  to  have  been 
very  favorable.  There  is  only  one  in  which  the  death  of  the  mother 
is  recorded ;  and  although  in  many  the  result  is  not  mentioned,  we 
may  fairly  assume  that  recovery  took  place. 

Among  difficulties  in  labor  some  of  the  most  important  are  due  to 
morbid  conditions  of  the  foetus  itself. 

Intra-uterine  Hydrocephalus. — Of  these  the  most  conmiou,  as  well 
as  the  most  serious,  is  caused  by  intra-uterine  hydrocephalus  (giving 

['  The  celebrated  Carolina  twins,  born  July  11,  1851,  and  still  living,  were  brought 
into  the  world  by  the  same  method,  but  the  mother,  having  a  large  pelvis,  "  had  a  brief 
and  easy  "  delivery.  Tiie  larger  of  the  two  girls  also  came  first,  as  in  the  Tzoni  case 
of  1701.  Tliese  twins  are  now  sixteen  years  older  than  the  Hungarian  sisters  were  at 
death,  and  will  soon  be  thirty-eight  years  old. — Ed.] 


378 


LABOR. 


rise  toj[a  collection  of  watery  fluid  witliin  tiie  craniuiii),  by  wliicli  the 
(liiiK'iisions  of  the  child's  lioad"  are  eiionnously  increased  and  the  due 
rc'hui(»us  between  it  and  the  i)elvie  eavitv  entirelv  destroyed) (FiL^ 
130).  '  •  ^      yv     fe 

Fortunately,  this  disease  is  of  c-oni})aratively  rare  oeeurrence,  for  it  is 
(one  of  great  gravity  both  as  regards  the  mother  and  child.  )  As  regards 
the  mother,  the  serious  character  of  the  complication  is  proved  by  the 

Fig.  130. 


Labor  Impeded  by  Hydrocephalus. 

statistics  of  Dr.  Keiller  of  Edinburgh,  who  found  that  out  of  74  cases 
no  less  than  16  were  accompanied  by  rupture  of  the  uterus.  The  reason 
of  the  danger  to  which  the  mother  is  subjected  is  obvious,  f  In  some  few 
cases,  indeed,  the  head  is  so  compressible  that,  ]>rovided  the  amount  of 
contained  fluid  be  small,  it  may  be  sufliciently  diminished  in  size  by  the 
moulding  to  which  it  is  subjected  to  admit  of  its  being  squeezed  through 
the  pelvis.)  In  the  majority  of  cases,  however,  the  size  of  the  head  is 
too  great  lor  this  to  occur.  (^  The  uterus  therefore  exhausts  itself,  and 
may  even  rupture,  in  the  vain  endeaTDr  to  overcome  thc~oT)stacle,  while 
the  large  aiicl  distended  head  presses  firmly  on  the  cervix,  or  on  the 
pelvic  ti.ssues  if  the  os  be  dilated,  and  all  the  evil  effects  of  prolonged 
com])ression  are  a]>t  to  follow. 

The  diagnosis  of  intra-uterine  hydrocephalus  is  by  no  means  so  easy 
as  the  descri])tion  in  obstetric  works  would  lead  us  to  believe.  It  is 
true  that  the  head  is  much  larger  and  more  rounded  in  its  contour  than 
the  healthy  fcetal  cranium,  aiTa  also  that  tlie  sutures  and  fontanclles  are 
more  wide  and  admit  occasionally  of  fluctuation  being  jierceivcd  through 
them.  Still,  it  is  to  be  remembered  that  the  head  is  always  arrested 
above  the  brim,  where  it  is  consequently  high  up  and  difticult  to  reach, 
and  where  these  peculiarities  are  made  out  with  much  difficulty.  As  a 
matter  of  fact,  the  true  nature  of  the  case  is  comparatively  rarely  dis- 


DYSTOCIA  FROM  FCETUS.  379 

covered  before  delivery;  thus  Chaussier'  found  that  in  more  than 
one-half  of  the  cases  he  collected  an  erroneous  diagnosis  had  been 
made. 

V  AVhenever  we  meet  with  a  ease  in  which  either  the  history  of 
])revious  labor  or  a  careful  examination  convinces  us  that  there  is  no 
obstacle  due  to  pelvic  deformity,  in  which  the  pains  are  strong  and 
forcing,  but  in  which  the  head  persistently  refuses  to  engage  in  the  brim, 
we  may  fairly  surmise  the  existence  of  hydrocephalus.  Nothing,  how- 
ever, short  of  a  careful  examination  under  anaesthesia,  the  whole  hand 
being  passed  into  the  vagina  so  as  to  explore  the  presenting  part  thor- 
oughly, will  enable  us  to  be  quite  sure  of  the  existence  of  this  compli- 
cation. Under  these  circumstances  such  a  complete  examination  is  not 
only  justified,  but  im})erative;  and  when  it  has  been  made  the  difficulties 
of  diagnosis  are  lessened,  for  then  we  may  readily  make  out  the  large 
round  mass,  softer  and  more  compressible  than  the  healthy  head,  the 
widely  separated  sutures,  and  the  fluctuating  fontanel les. 

Jn  a  considerable  proportion  of  cases — as  many,  it  is  said,  as  1  out  of 
5 — the  foetus  presents  by  the  breechJ  The  diagnosis  is  then  still  more 
difficult;  for  the  labor  ])rogresses  easily  until  the  shoulders  are  born, 
when  the  head  is  completely  arrested,  and  refuses  to  pass  with  any 
amount  of  traction  that  is  brought  to  bear  on  it.  Even  the  most  care- 
ful examination  may  not  enable  us  to  make  out  the  cause  of  the  delay, 
for  the  finger  will  impinge  on  the  comparatively  firm  base  of  the  skull, 
and  may  be  unable  to  reach  the  distended  portion  of  the  cranium.  At 
this  time  abdominal  palpation  might  throw  some  light  on  the  case,  for, 
the  uterus  being  tightly  contracted  round  the  head,  we  might  be  able 
to  make  out  its  unusual  dimensions.  The  wasted  and  shrivelled  appear- 
ance_of  the  child's  body  which  so  often  "accompanies  hydrocephalus 
would  also  arouse  suspicion  as  to  the  cause  of  delay.  (On  the  whole, 
such  cases  may  be  fairly  assumed  to  be  less  dangerous  to  the  mother 
than  when  the  head  presents!  for  in  the  latter  the  soft  parts  are  apt  to  be 
subjected  to  prolonged  pressure  and  contusion,  while  in  the  former  delay 
does  not  commence  till  after  the  shoulders  are  born,  and  then  the  charac- 
ter of  the  obstacle  would  be  sooner  discovered  and  appropriate  means 
earlier  taken  to  overcome  it. 

The  treatment  is  simple,  and  consists  in  tapping  the  head,  so  as 
to  allow  the  cranial  bones  to  collapse.  There  is  the  less  objection  to  this 
course,  since  the  disease  almost  necessarily  precludes  the  hope  of  the 
child's  surviving.  The  aspirator  would  draw  off  the  fluid  effectually, 
and  would  at  least  give  the  child  a  chance  of  life ;  and  under  certain 
circumstances  the  birth  of  a  child  who  lives  for  a  short  time  only  may 
be  of  extreme  legal  importance.  More  generally  the  perforator  will  be 
used,  and  as  soon  as  it  has  penetrated  a  gush  of  fluid  will  at  once  verify 
the  diagnosis.  ^^Schroeder  recommends  that  after  perforation  turning 
should  be  performed,  on  account  of  the  difficulty  with  which  the  flaccid 
head  is  propelled  through  the  pelvis\  This  seems  a  very  unnecessary 
complication  of  an  already  sufficiently  troublesome  ease.  As  a  rule, 
when  once  the  fluid  has  been  evacuated,  the  pains  being  strong,  as  they 
generally  are,  no  delay  need  be  apprehended.     Should  the  head  not 

'  Qazette  medicale,  1864. 


380  LABOR. 

cuiUL'  iloNvii,  the  ('0])1ki1( (tribe  may  be  a})plied,  Nvhicli  lakes  a  firmer  grasp 
than  the  forceps,  and  enables  the  liead  to  be  crushed  to  a  very  small  size 
and  readily  extracted. 

WIkii  the  brceeh  presents  the  head  nuist  be  perforated  through  the 
occipital  bone,  and  generally  this  may  be  acc(tnij)lished  behind  the  ear 
Avithont  nuich  ditlicnity.  In  a  case  of  Tarnier's  the  vertebral  column 
was  divided  by  a  bistoury  and  an  ela.stic  male  catheter  intnxluced  into 
the  vertebral  canal,  through  which  the  intracranial  fluid'  escaped,  the 
labor  being  terminated  s])ontaneously.^  In  any  case  in  which  it  is  found 
difficult  to  reach  the  skull  with  the  perforator  this  procedure  should 
certainly  be  tried. 

Other  forms  of  dropsical  efFusion  may  give  rise  to  some  difficulty, 
but  by  no  means  so  serious.  In  a  few  rare  ca*^es  tiie  thorax  has  been  so 
distended  with  fluid  as  to  obstruct  the  passage  of  the  child.  Asci^s  is 
somewhat  more  common,  and  occasionally  the  child's  bladder  is  so  dis- 
tended with  urine  as  to  prevent  the  birth  of  the  loody.  The  existence 
of  any  of  these  conditions  is  easily  ascertained ;  for  the  head  or  breech, 
whichever  haj)pens  to  present,  is  delivered  without  difficulty,  and  then 
the  rest  of  the  body  is  arrested.  This  will  naturally  cause  the  prac- 
titioner to  make  a  careful  exploration,  when  the  cause  of  the  delay 
will  be  detected. 

The  treatment  consists  in  the  evacuation  of  the  fluid_by^j2JJLliCtui"e- 
In  the  case  of  ascites  this  should  always  be  done,  if  possible,  by  a  fine 
trocar  or  aspirator,  so  as  not  to  injure  the  child.  This  is  all  the  more 
important  since  it  is  impossible  to  distinguish  a  distended  bladder  from 
ascites,  and  an  opening  of  any  size  into  that  viscus  might  prove  fatal, 
whereas  aspiration  would  do  little  or  no  harm  and  would  prove  quite  as 
efficacious. 

FcBtal  Tumors  Obstructing  Delivery. — Certain  foetal  tumors  may 
occasion  dystocia,  such  as  malignant  growths  or  tumors  of  the  kjdney, 
liver,  or  spleen.  Cases  of  this  kind  are  recorded  in  most  obstetric 
works.  Hydro-encephalocele  or  hydro-rachitis,  depending  on  defective 
formation  of  the  cranial  or  spinal  bones,  with  the  formation  of  a  large 
protruding  bag  of  fluid,  is  not  very  rare.  The  diagnosis  of  all  such 
cases  is  somewhat  obscure,  nor  is  it  jwssible  to  lay  down  any  definite 
rules  for  their  management,  which  must  vary  according  to  the  particidar 
exigencies.  /The  tumors  are  rarely  of  sufficient  size  to  ])rove  formidable 
obstacles  to Melivery,  and  many  of  them  are  very  compressible)  This 
is  specially  the  case  with  the  spina  bifida  and  similar  cystic  growths. 
Puncture — and  in  the  more  solid  growths  of  the  abdomen  t»r  thorax 
evisceration — may  be  required. 

Otlier  deformities,  such  as  the  anencephalous  foetus,  or  defective 
development  of  the  thorax  or  abdominal  parietes,  with  protrusion  of 
the  viscera,  are  not  likely  to  cause  difficulty,  but  they  may  much  em- 
barrass the  diagnosis  by  the  strange  and  unusual  presentation  that  is 
felt.  If  in  any  case  of  dou])t  a  full  and  careful  examination  be  under- 
taken, introducing  the  whole  hand  if  necessary,  no  serious  mistake  is? 
likelv  to  be  made. 

Dystocia  from  Excessive  Development  of  the  Foetus. — In  addi- 

*  Hergott,  Maladies  /(Stales  qui  peuvent  /aire  obstacle  d  P accouchement,  Paris,  1878. 


DYSTOCIA  FROM  FCETUS.  381 

tiou  to  dystocia  from  morbid  conditions  of  the  frctus,  difficulties  may 
arise  from  its  uinliif  development,  and  especially  from  excessive  size  and 
advanced  ossificaliun  of  the  skull.  This  last  is  especially  likely  to  cause 
delay.  Even  the  slight  difference  in  size  between  the  male  and  female 
head  was  found  by  Simpson  to  have  an  appreciable  effect  in  increasing 
the  difficulty  of  labor  when  the  statistics  of  a  large  number  of  cases 
were  taken  into  account ;  for  he  proved  beyond  doubt  that  tlie  difficul- 
ties and  casualties  of  labor  occurred  in  decidedly  larger  proportion  in 
male  than  in  female  births.  Other  circumstances  besides  sex  have  an 
important  effect  on  the  size  of  the  child.  Thus,  Duncan  and  Hecker 
have  shown  that  it  increases  in  proportion  to  the  age  of  the  mother  and 
the  frequency  of  the  labors  ;  while  the  size  of  the  parents  has  no  doubt 
also  an  important  bearing  on  the  subject. 

Although  these  influences  modify  the  results  of  labor  en  masse,  they 
have  little  or  no  practical  bearing  on  any  particular  case,  since  it  is 
impossible  to  estimate  either  the  size  of  the  head  or  the  degree  of  its 
ossification  until  labor  is  advanced. 

Treatment. — When  labor  is  retarded  by  undue  ossification  or  large 
size  of  the  head,  the  case  must  be  treated  on  the  same  general  princi- 
ples which  guide  us  when  the  want  of  proportion  is  caused  by  pelvic 
contraction.  Hence,  if  delay  arise  which  the  natural  powers  are  insuf- 
ficient to  overcome,  it  will  seldom  happen  that  the  disproportion  is  too 
great  for  the  forceps  to  overcome.  If  we  fail  to  deliver  by  it,  no 
resource  is  left  but  perforation. 

Large  size  of  the  body  of  the  child  is  still  more  rarely  a  cause  of 
difficulty,  for  if  the  head  be  born  the  compressible  trunk  will  almost 
always  follow.  Still,  a  few  authentic  cases  are  on  record  in  which  it 
was  found  impossible  to  extract  the  foetus  on  account  of  the  unusual 
bulk  of  its  shoulders  and  thorax.  Should  the  body  remain  firmly 
impacted  after  the  birth  of  the  head,  it  is  easy  to  assist  its  delivery 
by  traction  on  the  axillae,  by  gently  aiding  the  rotation  of  the  shoulders 
into  the  antero-posterior  diameter  of  the  pelvic  cavity,  and,  if  neces- 
sary, by  extracting  the  arras,  so  as  to  lessen  the  bulk  of  the  part  of  the 
body  contained  in  the  pelvis.  Hicks  relates  a  case  in  which  eviscera- 
tion was  required  for  no  other  apparent  reason  than  the  enormous  size 
of  the  body.  The  necessity  for  any  such  extreme  measure  must  of 
course  be  of  the  greatest  possible  rarity ;  and  it  is  quite  exceptional  for 
difficulty  from  this  source  to  be  beyond  the  powers  of  nature  to  over- 
come. 


382  LABOR. 


CHAPTER  XII. 

DEFORMITIES   OF   THE    PELVIS. 

Deformities  of  the  pelvis  form  one  of  the  most  important  subjects 
of  obstetric  study,  for  from  them  arise  some  of  the  gravest  difficuhies 
and  dangers  connected  uith  parturition,  A  kno\vle<lge,  therefore,  of 
their  causes  and  effects,  and  of  the  best  mode  of  detecting  them  eitlier 
during  or  before  hibor,  is  of  i)aramount  necessity ;  but  the  subject  is  far 
from  easy,  and  it  has  been  rendered  more  difficult  than  it  neetl  be  from 
over-anxiety  on  the  part  of  obstetricians  to  force  all  varieties  of  pelvic 
deformities  within  the  limits  of  their  favorite  classification. 

Difficulties  of  Classification. — ]\fany  attempts  in  this  direction 
have  been  made,  some  of  which  are  based  on  the  causes  on  which  the 
deformities  depend,  others  on  the  particular  kind  oT  deformity  })ro- 
duced.  The  changes  of  form,  however,  are  .soTarious  and  irregular, 
and  similar  or  apparently  similar  causes  so  constantly  produce  ditlerent 
eifects,  that  all  such  endeavors  have  been  more  or  less  unsuccessful. 
For  example(_we  find  that  rickets  (of  all  causes  of  jielvicdefcn-mity  the 
most  important)  generally  ]iroduces  a  narroj\\iiigjo£tlicconj+Hfale  diam- 
eter of  the  briml  Mhile  the  analogous  disease,  osteomalacia,  occurring 
in  adult  life,  generally  produces  a  contraction  of  the  traus\'ei"se  diame- 
ter, with  approximation  of  the  pubic  bones  and  relative  or  actual  elon- 
gation of  the  conjugate  diameter.'  AVe  might  therefore  be  temjited  to 
classify  the  results  of  these  two  disea.ses  under  .separate  heads  did  we 
not  find  that  when  rickets  affects  children  who  are  rumiing  about  and 
subject  to  mechanical  influences  similar  to  those  acting  upon  jnitients 
suffering  from  osteomalacia,  a  form  of  pelvis  is  produced  liardly  di.stiu- 
guishable  from  that  met  Avith  in  the  latter  disease,  which  by  .some  authore 
is  described  as  the  p.seudo-osteomalacic. 

On  the  whole,  therefore,  the  most  simple  as  well  as  the  most  scientific 
cla.ssification  is  that  which  takes  as  its  basis  the  particular  seat  and  nature 
of  the  deformity.     Let  us  first  glance  at  the  most  common  causes. 

Causes  of  Pelvic  Deformity. — The  key  to  the  ])articular  shape 
assumed  by  a  deformed  pelvis  will  be  found  in  a  knowledge  of  the  cir- 
cumstances which  lead  to  its  regular  development  and  normal  .<hape  in 
a  state  of  health.  The  changes  produced  may  almost  invariably  be 
traced  to  the  action  of  the  same  cau.ses  which  })roduce  a  normal  pelvis, 
but  which  under  certain  di.seased  C(»nditions  of  the  bones  or  articula- 
tions induce  a  more  or  less  serious  altei'ation  in  form.  The.se  liave  been 
already  described  in  di.scussing  the  normal  anatomy  of  the  jjelvis ;  and 
it  will  be  remembered  that  they  are  chiefly  the  weight  of  the  body, 
transmitted  to  the  iliac  bones  through  the  siicro-iliac  joints,  and  counter- 
pres.sure  on  these,  acting  through  the  acetabula.  Sometimes  they  act  in 
excess  on  bones  which  are  healthy,  but  possibly  smaller  than  usual,  and 
the  result  may  be  tlie  formation  of  certain  abnormalities  in  the  size  of 


DEFORMITIES  OF  THE  PELVIS.  383 

the  various  pelvic  diameters.  At  other  times  tliey  operate  on  bones 
which  are  softened  and  altered  in  texture  by  disease,  and  which  there- 
fore yield  to  the  ])r('ssure  far  more  than  healthy  bones. 

Rickets  and  Osteomalacia. — The  two  diseases  which  chiefly  ope- 
rate in  causing  deformity  are  rickets  and  osteomalacia.  Into  the  essen- 
tial nature  and  symi)tomatology  of  these  complaints  it  would  be  out  of 
place  to  enter  here :  it  may  suffice  to  remind  the  reader  that  they  are 
believed  to  be  pathologically  similar  diseases,  with  the  important  prac- 
tical distinction  that  the  former  occurs  in  early  life  before  the  bones  are 
completely  ossified,  and  that  the  latter  is  a  disease  of  adults  producing 
softening  in  bones  that  have  been  hardened  and  developed.  This  dif- 
ference affords  a  ready  explanation  of  the  generally  resulting  varieties 
of  pelvic  deformity. 

Rickets  commences  very  early  in  life — sometimes,  it  is  believed, 
even  in  utero.  It  rarely  produces  softening  of  the  entire  bones,  and 
only  in  case  of  very  great  severity  of  those  parts  of  the  bones  that  have 
been  already  ossified.  ''  The  effects  of  the  disease  are  principally  appar- 
ent in  the  cartilaginous  portions  of  the  bones,  in  which  osseous  deposit 
has  not  yet  taken  place;  The  bones,  therefore,  are  ijQj;  subject  .to. uni- 
form change,  and  this  fact  has  an  important  influence  in  determining 
their  shape.  Rickety  children  also  have  imperfect  muscular  develop- 
raentc  they  do  not  run  about  in  the  same  way  as  other  children,  they 
are  often  continuously  in  the  recumbent  or  sitting  posture,  and  thus  the 
M^eight  of  the  trunk  is  brought  to  bear,  more  than  in  a  state  of  health, 
on  the  softened  bonesj  ( For  the  same  reason  counter-pressure  through 
the  acetabula  is  absent  or  comparatively  slight;  When,  however,  the  dis- 
ease occurs  for  the  first  time  in  children  who  are  able  to  run  about,  the 
latter  comes  into  operation  and  modifies  the  amount  and  nature  of  the 
deformity.  It  is  to  be  observed  that  in  rickety  children  the  bones  are 
not  only  altered  in  form  from  pressure,  but  are  also  imperfectly  devel- 
oped, and  this  materially  modifies  the  deformity.  When  ossific  matter 
is  deposited  the  bones  become  hard  and  cease  to  bend  under  external 
influences,  and  retain  for  ever  the  altered  shape  they  have  assumed. 

In  osteomalacia,  on  the  contrary,  the  already  hardened  bones 
become  softened  uniformly  through  all  their  textures,  and  thus  the 
changes  which  are  impressed  upon  them  are  much  more  regular  and 
more  easily  predicated.  It  is,  however,  an  infinitely  less  common  cause 
of  pelvic  deformity  than  rickets,  as  is  evidenced  by  the  fact  that  in  the 
Paris  Maternity,  in  a  period  of  sixteen  years,  402  cases  of  deformity  due 
to  rickets  occurred  to  1  due  to  osteomalacia.^ 

Their  Varying-  Frequency. — The  frequency  of  both  diseases  varies 
greatly  in  different  countries  and  under  different  circumstances.  Rick- 
ets is  much  more  common  amongst  the  poor  of  large  cities,  whose  chil- 
dren are  ill-fed,  badly-clothed,  kept  in  a  vitiated  atmosphere,  and  sub- 
jected to  unfavorable  hygienic  conditions.  Deformities  are  therefore 
more  common  in  them  than  in  the  moT'e  healthy  children  of  the  upper 
classes  or  of  the  rural  population.  The  higher  degrees  of  deformity, 
necessitating  the  Csesarean  section  or  craniotomy,  are  in  England  of 
extreme  rarity ;  while  in  certain  districts  on  the  Continent  they  seem  to 

'■  Stanesco,  Recherches  cliniques  sur  les  Retrecissemenis  du  Bassin. 


384  LABOR. 

be  so  frequent  that  tliese  ultimate  resources  of  the  obstetric  art  have  to 
be  constantly  employed. 

In  anotlier  class  of  eases  the  ordinary  shape  is  modified  by  weijrht  and 
counter-j)ressure  o])erating  on  a  pelvis  in  Avhich  one  or  more  of  the 
articulations  is  ossified.  In  this  way  we  have  produced  the  obliquely 
om/c  pvlvis  of  Naeii;cle  or  the  still  more  uncommon  tranHvcrsehj  con- 
(rdcfcil  prlvis  of  H(il)ert. 

Other  Causes  of  Pelvic  Deformity. — A  certain  number  of  deformed 
pelves  cannot  be  referred  to  a  modification  of  the  ordinary  develop- 
mental chanoes  of  the  bones.  Amongst  tliese  are  the  deformities  result- 
ing from  sj)()ndyl-()listhesis,  or /down  ward  dislocation  of  tlie  lower  lum- 
bar vertcbiw^f  from  displacements  of  the  sacrum  caused  l)y  curvatures 
of  the  spinal  cohimn,  ])roduciug  the  kyphotic  and  scoliotic  pelves  ;  or 
from  diseases  of  the  pelvic  bones  themselves,  such  as  tumors,  malignant 
growths,  aiid  the  like. 

The  first  class  of  deformed  pelves  to  be  considered  is  that  in  Avhich 
the  diameters  are  altered  from  the  usual  standard  Avithout  any  definite 
distortion  to  the  bones ;  and  such  are  often  mere  congenital  variations 
in  size  for  which  no  definite  explanation  can  be  given.  Of  this  class  is 
the  pelvis  which  is  equally  enlarged  in  all  its  diameters  (j^elvis  (fquabili- 
terjusio  major),  which  is  of  no  obstetric  consequence,  except  inasmuch 
as  it  may  lead  to  precipitate  labor  and  is  not  likely  to  be  diagnosed 
during  life. 

The  corresponding  diminution  of  all  the  pelvic  diameters  (pelris 
(ecjuabiliterjiisto  minor)  may  be  met  with  in  women  who  are  apparently 
Avell  formed  in  every  respect,  and  whose  external  conformation  and  pre- 
vious history  give  n_o  Judication  of  the  abnormality.  Sometimes  the 
diminution  amounts  to  half  an  inch  or  more,  and  it  can  readily  be 
understood  that  such  a  lessening  in  the  capacity  of  the  pelvis  would  give 
rise  to  serious  difficulty  in  labor.  Thus,  in  3  cases  recorded  by  Xaegele 
a  fatal  result  followed — in  2  after  difficult  instrumental  delivery,  and  in 
the  third  after  rupture  of  the  uterus.  The  equally  lessened  pelvis,  how- 
ever, is  of  great  rarity.  An  unusually  small  j)elvis  may  be  met  with  in 
connectioii  witli  general  small  size,  as  in  dwarfs.  It  does  not  necessarily 
follow  that  because  a  woman  is  a  dwarf  the  pelvis  is  too  small  for  par- 
turition. On  the  contrary,  many  such  women  have  borne  children 
without  difficulty. 

[We  may  be  greatly  deceived  by  the  external  characteristics  of  a  large 
and  tall  woman  as  to  the  presumed  development  of  her  pelvis,  and  be 
led  to  credit  her  with  diameters  far  beyond  the  actual  measurements. 
In  a  lady  above  the  average  height,  with  large  hips  and  now  weighing 
over  two  hundred  ])()unds,  I  found  a  vagina  which  the  index  finger 
entered  with  difficulty,  and  a  pelvis  so  small  that  it  is  doubtful  if  she 
could  be  delivered  of  a  living  foetus  much  over  seven  months.  She 
bore  one  child  at  maturity,  which  M-as  delivered  after  its  death  with  if 
crushed  head,  at  the  end  of  three  days'  labor  and  after  long  and  power- 
ful traction  by  compressing  forceps.  She  has  a  tnicjusto  minor  pelvis. 
—Ed.] 

In  some  cases  a  pelvis  retains  its  infantile  characteristics  after  puberty 
(Fig.  131).     The  normal  development  of  the  pelvis  has  been  interfered 


DEFORMITIES  OF  THE  PELVIS.  385 

with,  possibly  from  premature  ossification  of  the  diiferent  portions  of 
llio  innominate  bones  or  from  arrest  of  tiieir  grcnyth  from  a  weakly  or 
rachitic  constitution.  The  measurements  of  these  pelves  are  not  always 
below  the  normal  standard  ;  they  may  continue  to  grow,  although  they 
have  not  developed.     The  proportionate  measurements  of  the  various 

Fig.  131. 


Adult  Pelvis  retaining  its  Infantile  Type. 

diameters  will  then  be  as  in  the  infant ;  and  the  antero-posterior  diam- 
eter may  be  longer  or  as  long  as  the  transverse,  the  ischia  comparatively 
near  each  other,  and  the  pubic  arch  narrow.  Such  a  form  of  pelvis  will 
interfere  with  the  mechanism  of  delivery  and  unusual  difficulty  in  labor 
Avill  be  experienced.  Difficulties  from  a  similar  cause  may  be  expected 
in  very  young  girls.  Here,  however,  there  is  reason  to  hope  that  as  age 
advances  the  pelvis  will  develop  and  subsequent  labors  be  more  easy. 

The  mascidw 1 6  or  fimuel -shaped  pelvis  owes  its  name  to  its  approx- 
imation to  the  type  of  the  male  pelvis.  The  bones  are  thicker  and 
stouter  than  usual,  the  conjugate  diameter  of  the  brim  longer,  and  the 
whole  cavity  rendered  deeper  and  narrower  at  its  lower  part  by  the 
nearness  of  the  ischial  tuberosities.  It  is  generally  met  with  in  strong, 
muscular  women  following  laborious  occupations,  and  Dr.  Barnes,  from 
his  experience  in  the  Royal  jNIaternity  Charity,  says  that  it  chiefly 
occurs  in  weavers  in  the  neighborhood  of  Bethnal  Green,  who  spend 
most  of  their  lime  in  the  sitting  posture.  "  The  cause  of  this  form  of 
pelvis  seems  to  be  an  advanced  condition  of  ossification  in  a  pelvis 
which  would  otherwise  have  been  infantile,  brought  about  by  the  devel- 
opment of  unusual  muscularity,  corresponding  to  the  laborious  employ- 
ment of  the  individual."  The  difficulties  in  labor  will  naturally  be  met 
Avith  toward  the  outlet,  where  the  funnel  shape  of  the  cavity  is  most 
ap])arent. 

Diminution  of  the  antero-posterior  diameter  {fattened  pelvis)  is  most 
frequently  liiiiited[to^ the  brim,  and  is  by  far  the  most  common  variety 
of  pelvic  deformity.     In  its  slighter  degrees  it  is  not  necessarily  depend- 

25 


386 


LABon. 


cut  on  rickets,  altli(»uy;li  when  iiinrc-  marked  it  almost  invariahlv  is  so. 
(\\  hen  iineoiiuected  with  i"iekets  it  prohaMy  can  Ijc  traced  to  some  inju- 
rious iutiuence  before  the  boues  have  os.silied,  such  as  increased  pres-ure 
ot"  the  trunk,  irom  ctirryin*;  wei<^ts  iu  early  ehildhocxl,  and  the  like. 
By  this  means  the  sacrum  is  uniluly  depressed  and  projects  ibrward,  s«» 
as  to  sliijhtly  narrow  the  conjugate  diameter. 

Mode  of  Production  in  Rickets. — ^^  hen  caused  by  rickets  the 
amount  ol"  tiie  contraction  varies  greatly,  sometimes  being  very  slight, 
sometimes  sufficient  to  ])revent  the  passage  ot"  the  child  altogether,  and 
necessitate  craniotomy  or  the  Ca^sarean  section.  TlitLJa.y:u.»b  soltened 
by  the  disease,  is  pressed  vertically  downward  by  the  Aveight  of  the 
body,  its  descent  being  partially  resisted  by  the  already  ossified  j)ortions 
of  the  bone, (go  that  the  result  is  a  downward  and  forward  movement  of 
the  promontory.  •  The  u})]x'r  portion  of  the  sacral  cavity  is  thus  directed 
more  backwai"d  ;  but,  as  the  aj)ex  of  the  bone  is  drawn  forward  by  the 
attachment  of  the  perineal  muscles  to  the  coccyx  and  by  the  Siicro-ischi- 
atic  ligaments,  a  .sharp  curve  of  its  lower  jjart  in  a  forward  direction  is 
established.  The  horizontal  rami  of  the  pui>es  are  also  flattened,  while 
the  ischia  are  more  widely  separated  than  in  a  normal  pelvis,  thus  pro- 
ducing a  greater  wid^tli  of  the  pubic  arch,  while  the  acetabnla  are 
turned  forward. 

The  depression  of  the  sacral  promontory  would  tend  to  produce 
strong  traction  through  the  sacro-iliac  ligaments  on  the  posterior  end  of 

Fig.  132. 


Scolio-rachltic  Pelvis. 
(From  a  spcciiiu'ii  in  tlic  Mnseuiii  of  St.  Bjirtliolomew's  Ilcispital.) 

the  sacro-cotyloid  beams,  and  thus  induce  expansion  of  the  iliac  bones 
and  consequent  increa.se  of  the  transverse  diameter  of  the  brim.  So  an 
unusual  length  of  the  transverse  diameter  is  verv  often  described  as 


DEFORMITIES  OF  THE  PELVIS. 


387 


accom])anyino-  this  dcluriiiity)^  but  j^robably  it  is  not  so  often  apparent 
as  might  otherwise  be  expected,  on  account  of  the  imperfect  develop- 
ment of  the  bones  generally  accompanying  rickets^  and  Barnes'  says 
that  in  the  parts  of  London  where  deformities  are  most  rife  any  enlarge- 
ment of  the  transverse  diameter  is  exceedingly  rare. 

Fre<][uently  the  sacrum  is  not  onlydepressed,  but  displaced  more  or 
less  to  one  side,  mosi  pncially  to  tHeleft,  thus  interfermg  with  the  reg- 
ular shape  of  the  dci'urined  brim.  This  is  often  the  result  of  a  lateral 
liexion  of  the  spinal  column,  depending  on  the  rachitic  diathesis,  and 
wlien  well  marked  is  known  as  the  scolio-rachitic  pelvis  (Fig.  132),  in 
which  one  side  of  the  pelvis,  that  corresponding  to  tlie  direction  of  the 
pelvic  curve,  is  asymmetrical  and  contracted,  the  ilio-pectineal  line  being 
sjiai^jjcur ved  iu,:5i:ard  about  the  site  of  the  sacro-iliac  synchondrosis, 
the  sympliysis  pubis  being  displaced  toward  the  opposite  side.  A 
somewhat  similar  but  much  less  marked,  unilateral  asymmetry  may 
exist  in  cases  of  scoliosis  [^]  unconnected  with  rickets,  but  rarely  to  a 
sufficient  degree  to  interfere  materially  with  labor. 

In  most  cases  of  this  kind  the  cavity  of  the  pelvis  is  not  diminished 
in  size,  and  is  often  even  more  than  usually  wide.  The  constant 
pressure  on  the  ischia  which  the  sitting  posture  of  the  child  entails 
tends  to  force  them  apart  and  also  to  widen  the  pubic  arch.     Consider- 

FiG.  133. 


Eickety  Pelvis,  with  backward  depression  of  symphysis  pubis. 

able  advantage  results  from  this  in  cases  in  which  we  have  to  perform 
obstetric  operations,  as  it  gives  plenty  of  room  for  manipulation. 

'  Lectures  on  Obst.  Operations,  p.  280. 

[^Although  liunchbacks  frequently  have  well-formed  pelves,  it  is  not  uncommon  to 
find  a  deformed  spine  associated  with  an  asymmetrical  pelvis  or  even  a  much  con- 
tracted one.  Spinal  distortion  from  caries,  "especially  in  the  lumbar  region,  is  thus 
associated,  and  the  pelvic  deforinity  will  be  increased  if  there  has  been  coxalgia, 
either  double  or  single,  or  if  from  any  cause  one  leg  sliould  be  shorter  than  "the 
other.  In  the  records  of  the  Porro  operation  we  find  under  "the  cause  of  diffi- 
culty," " pseudo-osteomalacia,"  "  liimbo-dorsal  ki/pho.ih,"  "  kyphoscoliosis,"  etc.  Pseiido- 
osteomalacia  is  the  result  of  rickets  in  a  walking  child,  "the  form  of  pelvis  being 
changed  meclianically,  as  in  osteomalacia.  Jjumbo-dorsal  kyphosis  may  or  mav  not 
give  rise  to  the  kyphotic  pelvis,  as  nnich  will  depend  upon  the  extent  of  vertebral 
caries._    Scoliosis  is  apt  to  result  from  rickets,  and  may  be  associated  with  lordosis. 

Scoliosis,  from  cr/voPiwf,  crooked— a  distortion  of  the  spine  to  one  side. 

Lordosis,  from  ?.op6oc,  curved— applied  particidarlv  to  the  forward  bending  of  the 
spine. 

Kyphosis,  from  Kvipuaic,  gibbous,  arched,  or  vaulted— a  hump  or  backward  curvature 
of  the  spine. — Ed.] 


38  S 


LABOR. 


Figure-of-eight  Deformity. — In  a  few  exceptional  cases  tlie  narrow- 
i'liL -'l-ilit'_^''-!-'''iiU5'itVLilJ^'"t>ter  is  increased  by  a  backward  depression 
of  tlie  syin]>hysis  j)ubis,  yliTdi  gives  tlie  pelvic  brim  a  sort  of  fiunre-of- 
eiglit  shape  (Fig.  lo-'i).  (The  most  reasonable  exj)lanation  of  this  jx-cn- 
liarity  seems  to  be  that(it  is  tiie  resnlt  of  the  mnscnlar  contraction  of  the 
recti  mnscles  at  their  point  of  attachment,  when  the  centre  of  gravity  of 
tlie  body  is  thrown  backward  on  acc-ount  of  the  projection  of  the  sacral 

promontory.)     Sometimes  also  the 
F^<'-  l-^^-  antero-})osterior    diameter    of    the 

cavity  is  nnnsually  lessened  by  the 
disappearance  of  the  vertical  curva- 
ture of  the  sacrum,  which  instead 
of  forming  a  distinct  cavity  is 
nearly  flat  (Fig.  134). 

Spondyl-olisthesis. — In  a  few 
rare  cases,  to  wliich  attention  was 
first  called  in  1853  by  Kilian  of 
Bonn,  a  very  formidable  narrow- 
ing of  the  conjugate  diameter  of 
the  pelvic  brim  ig,  produced  by  a 
downward  displacement  of  the 
_  foiirth  and  fifth  lumbar  vertebra'^; 

Flatness  of  Sacrum,  with  narrowing  of  pi'lvic    -which    bcCOmC    (lislocatcd     forward,, 

or,  if  not  actually  dislocated,  at 
least  separated  from  their  several  articulations  to  a  sufficient  extent 
to  encroach  very  seriously  on    the  dimensions    of    the    pelvic   inlet. 

This  condition  is  known  as  spondyl-olis- 
thesis  (Fig.  135). 

The  effect  of  this  is  sufficiently  obvi- 
ous, for  the  projection  of  the  lumbar 
vertebrae  prevents  the  passage  of  the 
child.  To  such  an  extent  is  obstruction 
thus  produced  that  in  the  majority  of 
the  recorded  cases  the  Cfesarean  section 
Mas  necessary.  The  true  conjugate  diam- 
eter, that  between  the  promontory  of  the 
sacrum  and  the  symphysis  pubis,  is  in- 
creased rather  than  diminished ;  but  for 
all  practical  pur])oses  the  condition  is  sim- 
ilar to  extreme  narrowing  of  the  conjugate 
from  rickets,  for  the  bodies  of  the  disj>lacc(l 
vertebrae  project  into  and  obstruct  the  ])el- 
vic  brim. 

The  cause  of  this  deformity  seems  to  be 

different  in  different  cases.   In  some  it  .«eems 

to  have  been  congenital,  and   in  othei's  to 

have  depended  'on/ some  antecedent  disease 

of  the  bones,) such  as  tuberculosis  or  scrofula,  producing  inflannnation 

and  softening  of  the  comicction  between  the  last  lumbar  vertebra  and 

the  sacrum,  thus  permitting  downward  displacement   of   the   bones.. 


Fig.  135. 


Pelvis  Deformed  by  Spondyl-olis- 
thcsis. 

(After  Kiliuu.) 


DEFORMITIES  OF  THE  PELVIS. 


389 


Laiiibl  believed  that  it  generally  luUowed  spina  bifida,  whieh  had 
become  partially  cured,  but  which  had  produced  deformity  of  the 
vertebra?  and  favored  their  dislocation.  Brodhurst,*  on  the  other 
hand,  thinks  that  it  most  probably  depends  on  raciiitic  inflammation 
and  softening-  of  the  osseous  and  ligamentous  structures,  and  that  it  is 
not  a  dislocation  in  the  strict  sense  of  the  word.  This  condition  has 
recently  been  made  the  subject  of  special  study  by  Dr.  Franz  L. 
Neugebauer,^  who  believes  that  the  forward  displacement  is  never  the 
result  of  antecedent  disease  of  the  bones,  but  depends  either  on  congen- 
ital want  of  development  of  the  vertebral  arches  or  on  traumatism,  such 
as  fracture  of  the  articular  processes,  which  allows  the  wefgfit  of  the 
trunk  to  displace  the  body  of  the  last  lumbar  vertebra  forward,  either 
jxartially  or  entirely. 

[We  are  indebted  to  Kilian  of  Germany  for  the  first  careful  investi- 
gation of  the  true  character  of  spondyl-olisthetic  deformity,  although 
the  credit  of  initial  mention  is  due 

to  Rokitansky  of  Austria,  who  wrote  Fig  1  ..h 

in  1839,  antedating  the  monograph 
of  the  former  (1853)  by  fourteen 
years.  No  special  mention  is  made 
of  this  peculiar  lordosis  by  Roki- 
tansky  in  his  Manual  of  Patholog- 
ical Anatomy  in  1844,  but  in  his 
Lehrhuch  (1855)  it  is  given,  with 
due  credit,  to  Kilian.  During  the 
thirty-three  years  that  have  passed 
since  Kilian  prepared  his  paper  from 
observations  made  upon  three  pelves 
^vhich  had  been  obtained  from  sub- 
jects in  whom  the  Cresareau  section 
had  proved  fatal,  one  of  them  after 
a  second  operation,  there  have  ap- 
peared numerous  monograplis  and 
descriptions  of  cases,  much  the  most 
valuable  and  extensive  of  which  are 
those  by  Dr.  Franz  Ludwig  Neuge- 
bauer  pf  Warsaw  and  Dr.  A.  Swedelin  of  St.  Petersburg,  the  latter  of 
whom  furnishes  the  bibliography  of  the  subject.  These  valuable  papers 
cover  223  and  40  pages  respectively  of  the  Archiv  fur  Gyndkologie, 
Berlin,  vols,  xix.,  xx.,  xxi.,  xxii.,  and  xxv.,  for  1882-85. 

V.The  most  frequent  origin  of  spondyl-olisthetic  deformity  appears  to 
lie  in  an  incomplete  ossification  of  the' last  lumbar  vertebra,  whereby  its 
anterior  and  posterior  portions  are  rendered  liable  to  separate  under 
the  superincumbent  weight  of  the  body.^  Hence  the  subjects  of  the 
slipplnc/  are  frequently  stout,  heavy  women.  This  was  markedly 
the  case  in  the  woman  who  came  under  the  care  of  Prof.  James 
Blake   of    San    Francisco.'^      This    patient   was    married    at    fifteen 

'  Obsf.  Trans.,  1865,  vol.  vi.  p.  97. 

^  Contribiidon  cl  la  Pathoqenie  du  Bamn  vide  par  le  Glissement  vertebral,  Paris,  1884. 

pPac.  Med.  and  Surg.  Journ.,  Feb.,  1867.] 


[Spondyl-olisthesis.     (After  Neugebauer.)] 


390  LABOR. 

yciirs  c»l"  a<:(',  :il  wliicli  time  .slio  \\fij::lic'<l  101  pounds,  but  iucrouxd 
to  191)  pounds  hy  the  time  her  first  child  was  born.  Her  fii-st 
and  second  hibors  were  tedious,  but  the  children  were  born  alive; 
she  aborted  of  another  fcetus  at  lour  months,  and  later  was  delivered 
at  maturity  (»!'  lour  others,  all  dead,  the  c(inju<i;ate  s])ace  in  the  seventh 
labor  bein<;-  computed  at  oo  inches.  This  labor  was  so  dillicult  that 
it  was  decided,  in  the  event  of  another  i>rctrnancy,  to  briufj;  on  labor 
prematurely.  She  became  pretjnant  for  tlie  eighth  time  at  the  age  of 
twenty-six,  when  she  weigiied  220  ])ounds.  Labor  was  induced  in  the 
seventh  month,  but  the  fcetus  was  lost,  as  it  weighed  nearly  six  pounds 
and  the  lumbo-])ubic  s]>ace  Mas  reduced  to  3  inches.  This  woman  is 
said  to  have  undergone  the  change  in  her  vertebne  witliout  j»ain  or  sign 
of  ill-health,  and  to  have  retained  a  remarkable  activity  for  her  weight. 
After  her  eighth  delivery  she  was  up  in  six  days  and  down  stairs  in  ten. 
The  history  of  this  case  would  indicate  that  the  deforming  process  must 
have  been  slowly  progressing  during  more  than  ten  years. 

In  contrast  with  this  painless  case  in  a  midtijiara  we  have  the  oppo- 
site in  a  nullipara,  reported  by  Dr.  Olshausen,  formerly  of  Halle.  The 
disease  commenced  in  his  patient  when  a  girl  of  eighteen  with  severe 
pains  in  the  sacrum  and  hips,  as  in  malacosteou.  She  had  not  had 
rickets  in  childhood,  had  enjoyed  good  health  up  to  this  time,  and  was 
quite  straight.  As  her  disease  progressed  she  found  on  awaking  one 
morning  that  she  could  not  straighten  her  spine,  and  was  forced  to  walk 
with  her  body  bent  forward.  She  was  jnit  under  medical  treatment  at 
the  surgical  clinic;  had  no  fever,  and  in  time  ceased  to  sutler,  and  was 
discharged.  Becoming  pregnant  at  the  age  of  twent}'-four.  Dr. 
Olshausen  delivered  her  in  1863  by  the  Cfesarean  section:  the  child 
lived,  but  she  was  lost  on  the  fourth  day  by  peritonitis.  The  lumbo- 
pubic  diameter  Mas  found  to  mcasvire  3  inches,  and  the  line  of  the  con- 
jugate struck  the  loMcr  margin  of  the  third  lumbar  vertebra. — Ed.] 

Spondyl-olizema. — A  somewhat  analogous  deformity  has  been  de- 
scribed by  PTergott '  under  the  name  of  suo)uJi/l-olizema.  In  this  the 
bodies  of  the  loMcr  lumb:ir  vertebra*  hnvin<f  been  destroyed  bv  caries,  the 
upper  lumbar  vertebra?  sink  doMuward  and  forward,  so  as  to  obstruct 
the  pelvic  inlet  and  prevent  the  engagement  of  the  foetus.  It  thus 
ditlers  from  sj^ondyl-olisthesis,  in  Mhich  there  is  dislocation,  but  not 
destruction,  of  the  bodies  of  the  lower  lumbar  vertebne. 

Deformity  from  Osteomalacia. — The  most  luarked  examjiles  of 
narrowing  of  both  oblique  diameters  depend  on  osteoiualacia.  In  this 
disease,  as  has  alTeady  i)een  remarked,  the  bonesf  are  uniibrmly  softened, 
and  the  alterations  in  form  are  further  influenced  bvTTie  fact  that  the 
disease  commences  after  union  of  the  separate  portions  of  the  ossa  in- 
nominata  has  been  completely  effected.  The  amoimt  of  deformity  in 
the  Morst  cases  is  very  great,  and  frequently  renders  delivery  impossible 
M'ithout  the  Cse-sarean  section.  ;  Sometimes  the  softening  of  the  bones 
proves  of  service  in  delivery,  by  admitting  of  the  dilatation  of  the  con- 
ti'acted  pelvic  diameter  by  the  pressure  of  the  presenting  part  or  even 
by  the  handl\  Some  curious  cases  are  on  record  in  which  the  deformity 
Mas  so  great  as   to  apparently  require  the  C'a'sarean   section,  but    in 

^  Arch,  lie  Tocoloyie,  1877,  p.  65. 


DEFORMITIES  OF  THE  PELVIS. 


391 


which  the  softened  bones  eventuiilly  yielded  sulliciently  to  render  this 
unnecessary. 

CTIic  weight  of  the  body  depresses  the  sacrum  in  ;i  vertical  directioji, 
and  at  the  same  time  compresses  its  component  parts  together,  so  as  to 
approximate  the  base  and  a])ex  of  the  bone  and  narrow  the  conjugate 
diameter  of  the  brim  by  causing  the  promontory  to  encroach  upon  it.' 
\The  most  characteristic  changes  are  produced  by  the  pushing  inward 
lof  the  walls  of  the  pelvis  at  the  cotyloid  cavities,  in  consequence  of 
pressure  exerted  at  these  points  through  the  femora.     The  effect  of 

Fig.  137. 


Osteomalacic  Pelvis.  P] 


this  is  to  diminish  both  oblique  diameters,  giving  the  brim  somewhat 
the  shape  of  a  trefoil  or  an  ace  of  clubs.     The  sides  of  the  pubes  are 


Fig.  138. 


Extreme  Degree  of  Osteomalacic  Deformity. 

at  the  .same  time  approximated,  and  may  become  almost  parallel,  and 
the  trite  conjugate  may  be  even  lengthened  (Fig.  137).     The  tuberosi- 

['  This  form  is  known  as  rostrate,  or  beaked.  Tlie  true  conjngate  measure  is  no 
indication  of  the  extent  of  deformity.  A  rachitic  pelvis  of  this  form  in  front  is  termed 
a  pseudo-malacic  one. — Ed.] 


392  LABOR. 

ties  of  the  isohia  are  also  c()nipre.sseJ  together,  with  the  rest  ol"  the 
lateral  pelvic  -wall,  so  that  the  outlet  is  greatly  deformed  as  well  as 
the  brim  (Fig.  138). 

[Osteomalacia  not  an  American  Disease. — In  not  oue  of  the  183 
Csesarean  operations  of  the  United  States  was  the  operation  })erfoi-med 
for  this  kind  of  deformity.  The  disease  has  sometimes  been  met  with  in 
foreigners  who  have  been  delivered  by  the  forceps  or  craniotomy.  Jiut 
few  American  accoucheurs  have  ever  seen  a  case,  and  I  have  not  heard  of 
an  extreme  rostrate  pelvis  having  been  met  with  in  our  country. — Ed.] 
Obliquely-contracted  Pelvis. — That  form  of  deformity  in  Mhich 
/one  oblique  diameter  only  is  lessened  lias  received  considerable  attention 
from  having  been  made  the  subject  of  special  study  by  Xaegele,  and  is 
generally  known  as  the  obliquely-contr acted  pelvis  (Fig.  139).     It  is 

a  condition   that   is  very  rarely  met 
Fig.  139.  with,  although  it  is  interestmg  from 

an  obstetric  point  of  view,  as  throw- 
ing considerable  light  on  the  mode  in 
which  the  natural  development  of  the 
pelv^is  is  affected,  (it  is  difficult  to  diag- 
nose, inasmuch  as  there  is  no  apparent 
external  deibrmity,  and  probably  it  has 
never,  in  fact,  been  detected  before  de- 
livery.) It  has  a  very  serious  influence 
on  labor :  Litzmann  found  that  out  of 
28  cases  of  this  deformity,  22  died  in 
their  labors  and  5  more  in  subsequent 
^^'^'"'TSi^vTun^il^'^"''^-  deliveries.  T The  prognosis,  therefore,  is 

very  formidable^  and  renders  a  Icnow- 
ledge  of  this  distortion,  rare  though  it  be,  of  imjjortauce. 

Its  essential  characteristic  is  flattening  and  want  of  develo]tment  of 
one  side  of  the  pelvis,  asspciated  with  anky](i>i>  of  tlic  <nrr( -]H,ii(ling 
sacro-iJ[iac.syucKoiadi'Osis.     The  latter  i<  ])robably  always  pre.-fiit,  and  it 
seems  to  be  most  generally  a  congenital  malformation.     The  lateral  half 
of  the  sacrum  on  the  same  side,  and  the  entire  innominate  bone,  are 
much  atrophied.    The  promontory  of  the  sacrum  is  directed  toward  the 
diseased  side  and  the  symphysis  pubis  is  pushed  toward  the  healthy  side. 
( The  main  agent  in  the  production  of  this  deformity  is  the  absence  of 
the  sacro-iliac  joint,  which  prevents  the  projier  lateral  expansion  of  the 
pelvic  brim  on  that  side,  and  allows  the  counter-pressure  through  the 
femur  to  push  in  the  atrophied   os  innominatum  to  a  much   greater 
extent  than  usual.  {The  chief  diminution  in  the  length  of  the  pelvic  i 
diameter  is  between  the  ilio-pectiueal  eminence  of  the  afl^'ected  side  audi 
the  healthy  sacro-iliac  joint,  M'hile  the  oblique  diameter  between  thel 
aukylosed  joint  and  the  healthy  os  innominatum  is  of  normal  length.)) 

[Coxalffla  in  young  subjects  will  produce  a  form  of  obliquely-con- 
tracted pelvis,  the  ilium  being  stunted  in  growth,  as  well  as  the  cor- 
responding extremity,  and  the  superior  strait  rendered  small  aaid 
D-shaped.  Cases  of  this  deformity  have  been  four  times  operated  upon 
in  the  United  States  by  the  Oi^sarean  section. — Ed.] 

Narrowing  of  the  Transverse  Diameter. — Transverse  contraction 


DEFORMITIES  OF  THE  PELVIS. 


393 


of  the  pelvic  brim  is  very  niucli  less  ccjiiimoii  than  narrowing  of  the 
conjugate  diameter.  It  most  frequently  cle"pends  on  backward  curva- 
ture of  the  loM-er  parts  of  the  spinal  column  in  consequence  of  disease 
of  the  vertebrae.  This  form  of  deformed  pelvis  is  generally  known  as 
the  kjfj)hotlc  (Fig.  140).  (The  effect  of  the  spinal  curvature  is  to  drag 
the  promontory  of  the  sac- 
rum backward,  so  that  it  is  Fig.  140. 
high  up  and  out  of  reach^ 

(By  this  means  the  antero- 
posterior diameter  of  the 
brim  is  liicreased,  while  the 
traugyerse  is  lessened  J  the 
relative  proportion  between 
the  two   is   thus    reversed. 

AV^hile  the  upper  portion 
of  the  sacrum  is  displaced 
backward,  its  lower  end  is 
projected  forward,  so  that 
the  antero-posterior  diame- 
ters of  the  cavity  and  out- 
let are  considerably  dimin- 
ished. )(The  ischial  tuberosi-\ 
ties  are  also  nearer  to  each', 
other  and  the  pubic  arch  is 
narrowed.;  Obstruction  to 
delivery  will  be  chiefly  met 
with  at  the  lower  parts  and 
outlet  of  the  pelvic  cavity; 
for,  although  the  transverse 
diameter  of  the  brim  is  nar- 
rowed, there  is  generally  suf- 
ficient space  for  the  passage 
of  the  head. 

Robert's  Pelvis. —  An- 
other form  of  transversely-contracted  pelvis  is  known  as  Robert's  pelvis 
(Fig.  141),  having  been  first  discovered  by  Kobert  of  Coblentz.  It 
is  in  faclj  a  double  obliquely-coutracted 
pelvis,  depending  on  ankylosis  of  both 
sacro-iliac  joints,  and  consequent  defec- 
tive development  of  the  innominate 
bones.  I  The  shape  of  the  pelvic  brim 
is  markedly  oblong,  and  the  sides  of 
the  pelvis  are  more  or  less  parallel 
with  each  other.  The  outlet  is  also 
much  contracted  transversely.  The 
amount  of  obstruction  is  very  great, 
so  that,  according  to  Schroeder,  out  of 
7  well-authenticated  cases,  the  Ceesa- 
rean  section  was  required  in  6. 

T\^-(>^ .,;4.„       -p     „         r\^^  ^-i -^^i^^     Robert's,  or  double  obliquely-contracted 

Deformity      from      Old-standmg  j-eivis.   (After  DunJau.;  - 


Kyphotic  Pelvis. 
(Fi'om  a  specimen  in  the  Museum  of  St.  Bartholomew's  Hospital.) 


394 


LABOR. 


Fig.  142. 


Hip-joint  Disease. — Anotlicr  cause  ol"  transvenso  defbrn^ijj}'  <»c'ea.-5ion- 
ally  met  with  is  luxation  of  the  head  of  the  femur  depending  on  old- 
standing  joint  disease.  The  head  of  the  femur  in  this  case  presses  on 
the  innomintite  bone  at  the  site  of  dislocation,  and  the  result  is  that  the 
iliac  fossa  on  the  affected  side,  or  both  if  the  accident  ha])pens  on  both 
sides,  is  pushed  inward,  the  transverse  diameter  of  the  brim  being  less- 
ened. The  tuberosity  of  the  ischium  is,  however,  projected  outward,  so 
that  the  outlet  of  the  jielvis  is  increased  rather  than  diminished. 

Deformity  from  Tumors,  Fractures,  etc. — Obstruction  of  the 
])elvic  cavity  from  exostoses  or  other  forms  of  tumors  growing  from 
the  bones  is  of  great  rarity  (Fig.  142).  It  may,  hoAvever,  produce 
"~  very  serious  dystocia.    Several  curious 

examples  are  collected  in  Mr.  A^^ood's 
article  on  the  pelvis,  in  some  of  %vhich 
the  obstruction  was  so  great  as  to  ne- 
cessitate the  Csesarean  section.  Some 
of  these  growths  were  true  exostoses, 
and,  according  to  stadfeldt,^  these  are 
commonly  found  in  pelves  that  are 
otherwise  contracted  ;  others,  osteo- 
sarcomatous  tumors  attached  to  the 
pelvic  bones,  most  generally  the  ui)per 
part  of  the  sacrum ;  and  others  Avere 
malignant.  In  some  cases  spicuhe  of 
bone  have  developed  about  the  iinea 
nio-jiectinea  or  other  parts  of  the  pel- 
vis, which  may  not  be  sufficient  to 
produce  obstruction,  but  which  may 
injure  the  uterus,  or  even  the  fo'tal 
head,  Avhen  they  are  pressed  upon 
them.  Irregular  })rojections  may 
also  arise  from /the  callus  of  old 
fractures  of  the  pelvic  bones.N  All  such  cases  deiy  classification,  and 
differ  so  greatly  in  their  extent  and  in  their  effect  on  labor  that  no  rules 
can  be  laid  down  for  them,  and  each  must  be  treated  on  its  own  merits. 
The  effects  of  pelvic  contractions  on  labor  vary,  of  coui'se, 
greatly  with  the  amount  and  nature  of  the  deformity,  but  they  must 
always  give  rise  to  anxiety,  and  in  the  graver  degrees  they  produce  the 
most  serious  difficulties  we  have  to  contend  with  in  the  whole  range  of 
obstetrics. 

(  In  the  lesser  degrees,  in  which  the  proportion  between  the  presenting 
part  and  the  pelvis  is  only  slightly  altered,  we  may  observe  little  al)nor- 
mal  beyond  a  greater  intensity  of  the  jxiins  and  some  protraction  of  the 
labor:  It  is  generally  observed  that  the  uterine  contractions  are  strong 
and  forcible  in  cases  of  this  kind,  probably  because  of  the  increased 
resistance  they  have  to  contend  against ;  and  this  is  obviously  a  desir- 
able and  conservative  occurrence,  which  may  of  itself  suffice  to  overcome 
the  difficulty.  The  first  stage,  however,  is  not  unfVequently  prolonged, 
and  the  pains  are  ineffective,  for  the  head  does  not  readily  engage  in  the 

1  Obstetrical  Journal,  1879-80,  vol.  vii.  p.  201. 


Bony  Growth  from  Sacrum  obstructing 
the  I'elvic  Cavity. 


DEFORMITIES  OF  THE  PELVIS.  395 

brim,  the  uterus  is  more  mobile  than  in  ordinary  labors,  and  it  probably 
acts  at  a  disadvantage. 

Risks  to  the  Mother.-(-Tu  the  more  serious  eases  the  mother  is  suIj- 
jected  to  many  risks  directly  proportionate  to  the  amount  of  obstruction 
and  the  length  of  the  labor.)  The  long-contiinicd  and  excessive  uterine 
action,  produced  by  the  vain  endeavors  to  push  the  child  through  the 
contracted  pelvic  canal,  the  more  or  less  prolonged  contusion  and  injury 
to  which  the  maternal  soft  parts  are  necessarily  subjected  (not  unfre- 
quently  ending  in  inflammation  and  sloughing  with  all  its  attendant 
dangers),  and  the  direct  injury  which  may  be  inflicted  by  the  measures 
we  are  compelled  to  adopt  for  aiding  delivery  (such  as  the  forceps, 
turning,  craniotomy,  or  Csesarean  section),  all  tend  to  make  the  progno- 
sis a  matter  of  grave  anxiety.  [The  Csesarean  operation  has  been  per- 
formed 9  times  in  the  United  States  in  cases  of  pelvic  exostosis,  with  4 
recoveries.  One  woman  was  operated  upon  three  times  and  died  from  the 
third  operation :  4  of  the  9  children  were  saved.  Of  the  fatal  cases,  3 
were  in  labor  three  days,  1  two  days  and  1  had  been  in  convulsions  for 
twenty-four  hours.  Of  the  4  that  recovered,  1  was  in  labor  "  a  few 
hours;"  1,  twelve  hours;  1,  twenty-four  hours;  and  1,  thirty-eight 
hours. — Ed.] 

Risks  to  the  Child.— ^or  are  the  dangers  less  to  the  child,  and  a 
very  large  proportion  of  stillbirths  will  ahvays  lie  met  with.^  The  infan- 
tile mortality  may  be  traced  to  a  variety  ol'  causes,  the  most  important 
being  the  pi;otraction  of  the  labor  an(l"tlVe  continuous  pressure  to  which 
the  presenting  part  is  subjected.  For  this  reason,,  even  in  cases  in  which 
the  contraction  is  so  slight  that  the  labor  is  terminated  by  the  natural 
poAvers,  it  has  been  estimated  that<bne  out  of  every  five  children  is  still- 
born ;  )and  as  the  deformity  increases  in  amount,  so  of  course  does  the 
prognosis  to  the  child  become  more  unfavorable, 
(f  Prolapse  of  the  umbilical  cord  is  of  very  fregueut  occurrence  in 
cases  of  pelvic  deformity,  the  tendency  to  this  accident  being  traceable 
to  the  fact  of  the  head  not  entering  and  occupying  the  upper  strait  of 
the  pelvis  as  in  ordinary  labors,  and  thus  leaving  a  space  through  which 
the  cord  may  descend.  V  So  frequently  is  this  complication  met  with  in 
pelvic  deformity  that  Stanesco  found  it  had  happened  as  often  as  59 
times  in  414  labors;  and  when  the  dangers  of  prolapsed  funis  are  added 
to  those  of  protracted  labors,  it  is  hardly  a  matter  of  surprise  that  the 
occurrence  should,  under  such  circumstances,  almost  always  prove  fatal 
to  the  child. 

(The  head  of  the  child  is  also  liable  to  injury  of  a  more  or  less  grave 
character  from  the  compression  to  which  it  is  subjected,  especially  by 
the  promontory  of  the  sacrum.  ;  Independently  of  the  transient  effects 
of  undue  pressure  (temporary  alteration  of  the  shape  of  the  bones  and 
bruising  of  the  scalp),  there  is  often  met  with  a  more  serious  depression 
of  the  bones  of  the  skull,  produced  by  the  sacral  promontory.  This  is 
most  marked  in  cases  in  which  the  head  has  been  forcibly  dragged  past 
the  projecting  bone  by  the  forceps  or  after  turning.  The  amount  of 
depression  varies  with  the  degree  of  contraction  ;  but  sometimes,  were 
it  not  for  the  yielding  of  the  bones  of  the  foetal  skull  in  this  way,  deliv- 
ery without  lessening  the  size  of  the  head  by  perforation  would  be 


396  LABOR. 

impossible.  Such  depressions  are  found  at  the  spot  immediately  ()})p(j- 
site  the  })roniontory,  generally  at  the  side  of  the  skull  near  the  junction 
of  the  frontal  and  parietal  bones.  Sometimes  there  is  a  slight  pei'ma- 
nent  mark,  but  more  often  the  depression  disappears  in  a  few  days.  The 
prognosis  to  the  child  is,  however,  grave  when  the  contraction  has  been 
sullicicnt  to  indent  the  skull,  for  it  has  been  found  that  oO  per  cent,  of 
the  cliildren  thus  marked  died  either  inunediately  or  shortly  after 
labor.' 

Course  of  Labor. — The  means  which  nature  takes  to  overcome 
these  difficulties  are  well  worthy  of  study,  and  there  are  certain  peculi- 
arities in  the  mechanism  of  delivery  when  pelvic  deformities  exist 
wliich  it  is  of  importance  to  understand,  as  they  guide  us  in  determining 
the  proper  treatment  to  ado])t. 

Frequency  of  Malpresentation.— (iNIalpresentations  of  the  foetus  are 
of  much  more  frcqj.ient  occurrence  than  in  ordinary  labors;  i)artly 
because  the  head  does  not  engage  readily  in  the  brim,  but,  remaining 
free  above  it,  is  apt  to  be  pushed  away  by  the  uterine  contractions,  and 
partly  because  of  the  frequent  alteration  of  the  axis  of  the  uterine 
tumor.  The  pendulous  condition  of  the  abdomen  in  cases  of  pelvic 
delbrmity  is  often  very  obvious,  so  that  the  fundus  is  sometimes  almost 
in  a  line  with  the  cervix,  and  thus  transverse  or  other  abnormal  positions 
are  very  frequently  met  with.  It  is  to  be  noted,  however,  that  we  can- 
not regard  breech  presentations  as  so  unfavorable  as  in  ordinary  lal)ors) 
for  the  pressure  from  the  contracted  pelvis  is  less  likely  to  be  injurious 
when  applied  to  the  body  than  to  the  head  of  the  child  ;  and,  incleed,  as 
we  shall  presently  see,  the  artificial  production  of  these  presentations  is 
often  advisal^le  as  a  matter  of  choice. 

Mechanism  of  Delivery  in  Head  Presentations. — The  mode  in 
Avhich  the  head  passes  naturally  through  a  contracted  pelvis  is  in  some 
respects  different  from  the  ordinary  mechanism  of  delivery  in  head 
presentations,  and  has  been  carefully  worked  out  by  Spiegelberg  and 
other  German  obstetricians. 

The  means  which  nature  adopts  to  overcome  the  difficulty  are  differ- 
ent in  cases  in  which  there  is  a  marked  narrowing  of  the  conjugate 
diameter  of  the  brim  and  in  those  in  which  there  is  a  generally-con- 
tracted pelvis. 

a.  In  Contracted  Brim.— ^In  the  former  and  more  common 
deformity  the  head  lies  at  the  brim  with  its  long  occipi to-fron- 
tal diameter  in  the  transverse  diameter  of  the  pelvis,  and,  as 
both  parietal  bones  cannot  enter  the  contracted  brim,  it  lies  with 
one  parietal  bone  on  a  much  lower  level  than  the  other,  in  the 
large  majority  of  cases  that  nearest  the  pubcs  l)cing  most  depressed, 
so  that  the  sagittal  suture  is  felt  high  up  near  the  promontory  of  the 
sacrum  (Fig.  143).)  x\.s  labor  advances,  if  the  contraction  is  not  too 
great  to  be  insuperable,  the  anterior  fontanelle  comes  much  more  within 
reach  than  in  ordinary  labor,  Avhilc  at  the  same  time  the  occipital  por- 
tion of  tlie  hca<l  is  shoved  to  the  side  of  the  pelvis,  so  that  its  narrow 
bitem])ora]  diameter  engages  in  the  contracted  conjugate.  At  tliis  stage, 
on  examination,  it  will  be  found — supposing  we  have  to  do  with  a  case 

^  Schroeder,  op.  cit.,  p.  256. 


DEFORMITIES  OF  THE  PELVIS. 


397 


Fig.  143. 


Head  passing  through  the  Inlet 
in  Flat  Pelvis.    (After  Parvin.) 


in  which  the  occiput  points  to  the  left  side  in  the  pelvis — that  the  ante- 
rior fontanel  le  is  lower  than  the  posterior  and  to  the  right,  that  tlie 
bitemporal  diameter  of  tlie  head  is  engaged  in  the  conjugate  diameter 
of  the  brim  (as  the  smallest  diameter  of  the  skull  tlierc  is  manifest  ad- 
vantage in  this),  and  that  the  bi])arietal  di- 
ameter and  the  largest  portion  of  the  head 
points  to  the  left  side.  The  sagittal  suture 
will  be  felt  running  across  in  the  transverse 
diameter  of  the  brim,  but  nearer  to  the  sa- 
crum, the  head  being  placed  obliquely.  As 
the  head  is  forced  down  by  the  uterine  con- 
tractions, the  parietal  bone,  which  is  resting 
on  the  promontory,  is  pushed  against  it,  so 
that  the  sagittal  suture  is  forced  more  into 
the  true  transverse  diameter  of  the  pelvic 
brim,  and  approaches  nearer  to  the  pubes. 
The  next  step  is  the  depression  of  the  head, 
the  occiput  undergoing  a  sort  of  rotation  on 
its  transverse  axis,  so  that  it  reaches  a  plane 
below  the  brim.  When  this  is  accomplished 
the  rest  of  the  head  readily  passes  the  ob- 
struction. The  forehead  now  meets  with 
the  resistance  of  the  pelvic  Avails,  the  posterior  fontanelle  descends  to  a 
lower  level,  and,  as  the  cavity  of  the  pelvis  in  cases  of  autero-posterior 
contraction  of  the  brim  is  generally  of  normal  dimensions,  the  rest  of 
the  labor  is  terminated  in  the  usual  way. 

h.  In  Generally-contracted  Pelvis. — In  the  generally-contracted 
pelvis  the  head  enters  the  brim  with  the  posterior  fontanelle  lowest, 
and  it  is  after  it  has  engaged  in  it  that  the  resistance  to  its  progress 
becomes  manifest.  /The  result  is,  therefore,  an  exaggeration  of  what 
is  met  with  in  ordinary  cases.l  The  resistance  to  the  anterior  or  longer 
arm  of  the  lever  is  greater  than  that  to  the  occipital  or  shorter,  and 
therefore  ^ the  flexion  of  the  head  becomes  very  marked  ](Fig.  144). 

The  posterior  fontanelle  is  consequently  un- 
usually depressed,  and  the  anterior  quite  out 
of  reach.  So  the  head  is  forced  down  as  a 
wedge,  and  its  further  progress  must  depend 
upon  the  amount  of  contraction.  If  this  be 
not  too  great,  the  anterior  fontanelle  eventu- 
ally descends,  and  delivery  is  completed  in 
the  usual  way.  Should  the  contraction  be 
too  much  to  permit  of  this,  the  head  becomes 
jammed  in  the  pelvis  and  diminution  of  its 
size  may  be  essential. 

In  cases  of  deformity  of  the  conjugate  dia- 
meter, combined  with  general  contraction  of 
the  pelvis,  the  mechanism  partakes  of  the 
peculiarities  of  both  these  classes  to  a  greater 
or  less  extent,  in  proportion  to  the  preponder- 
ance of  one  or  other  species  of  deformity. 


Fig 


Marked  Flexion  of  the  Head  en- 
tering a  Generally-contracted 
Pelvis.    (After  Parvin.) 


i| 


398  LABOR. 

Diagnosis. — It  rarclv  li:ii)|U'ii>  thai  (Irlnrniitics  oi"  tin-  [R-lvis,  except 
of  tlie  gravest  kind,  are  .siispeited  hetore  labor  hits  actually  cominenciHl, 
ami  therefor^  we  are  not  often  CiiUed  upon  to  give  an  opinion  as  t(j  the 
c(»ndition  of  the  j)elvi.s  before  delivery.  Should  we  be,  there  are  various 
<'iren instances  ^hich  may  aid  us  in  arriving  at  a  correct  conelasion. 
Prominent  among  them  is  the  liistop-  of  the  patient  in  childho(Ml.  If 
she  is  known  to  have  sutt'ered  from  rickets  in  early  life,  more  especially 
if  the  disease  has  left  evident  traces  in  deformities  of  the  lind)s  or  in  a 
dwarfed  and  stunted  growth  or  in  curvature  of  the  spine,  there  will  l)e 
strong  presumptive  evidence  of  pelvic  deformity  ;(a  markedly  jiendu- 
lous  state  of  the  abdomen  juay  also  tend  to  connrm  the  suspicion^ 
Xothing  short  of  a  careful  examination  of  the  pelvis  itself  will,  how- 
ever, clear  up  the  point  with  certainty;  and  even  l)v  this  means  to 
estimate  the  precise  degree  of  deformity  with  accuracy  requires  con- 
siderable skill  and  practice.  The  ingenuity  of  practitioner's  has  been 
much  exercised — it  might  perhaps  be  justly  said  wasted — in  the  inven- 
tion of  various  more  or  less  complicated  pelvimeters  for  aiding  us  in 
obtaining  the  desired  object.  It  is,  however,  pretty  generally  admitted 
bv  all  accoucheurs  that  the  hand  forms  the  best  and  most  relialjle  instru- 
ment for  this  purpose — at  any  rate,  as  regards  the  interior  of  the  pelvis ; 
although  a  pair  of  callipers,  such  as  Baudelocque's  well-known  instru- 
ment, is  essential  for  accurately  determining  the  external  measurements. 
The  objections  to  all  internal  pelvimeters,  even  those  most  simj)le  in 
their  construction,  are  their  cost  and  complexity  and  the  impossibility 
of  using  them  without  pain  or  injury  to  the  patient. 

It  was  formerly  thought  that  by  measuring  the  distance  l)etween  the 
spinous  processes  of  the  sacrum  and  the  symphysis  pubis,  and  subtract- 
ing from  it  what  we  judge  to  be  the  thickness  of  the  bones  and  soft 
parts,  we  might  arrive  at  an  approximate  estimate  of  the  measurement 
of  the  conjugate  diameter  of  the  pelvic  brim,  ^t  is  now  admitte<l  that 
this  method  can  never  be  depjended  on,  and  that,  taken  by  itself,  it  is 
practically  useless^^A  change  in  the  relative  length  of  our  external 
measurements  of  the  pelvis  is,  however,  often  of  great  value  in  show- 
ing the  existence  of  deformity  internally,  although  not  in  judging  of 
its  amount.  /  The  measurements  Avhich  are  used  fortius  purpose  are 
between  theimterior  suj)erior  spines  of  the  ilia  and  between  the  centres 
of  their  crests,  averaging  respectively  10  and  11  inches.  According  to 
Spiegelberg,  these  measurements  may  give  one  of  three  results : 

1.  Both  may  be  less  than  they  ought  to  be,  but  the  relation  of  one  to 
±he  other  remains  unchanged. 

2.  That  between  the  crests  is  not,  or  is  at  most  very  little,  diminished, 
but  that  betMeen  the  spines  is  increased. 

3.  Both  are  diminished,  but  at  the  same  time  their  mutual  relation 
is  not  normal,  the  distance  between  the  spines  being  as  long  as,  if  not 
longer  than,  that  between  the  crests. 

Xo.  1  denotes  a  uniformly-contracted  pelvis ;  Xo.  2,  a  pelvis  simply 
contracted  in  the  conjugate  diameter  of  the  brim,  and  not  otherwise 
deformed  ;  Xo.  3,  a  pelvis  with  narroMcd  conjugate  and  also  uniformly 
contracted,  as  in  the  severe  type  of  rachitic  deformity.  If,  however, 
both   these   measurements   are   of    average   length    and    the   distance 


DEFORMITIES  OF  THE  PELVIS. 


399 


between  the  crests  is  about  one  inch  greater  than  between  the  spines, 
the  pelvis  is  normal. 

Besides  the  above,  some  information  may  be  obtained  by  the  measure- 
ment of  the  external  con) ugatc  diameter,  which  averages  7|-  inches. 
This  may  bo  taken  by  jiTacing  one  point  of  the  callipers  in  the  depres- 
sion below  the  spiue  of  the  last  lumbar  vertebra,  the  other  at  the  centre 
of  the  upjjer  edge  of  the  symphysis  pubis.  If  tiie  measurement  be 
distinctly  belovv^  the  average — not  more,  for  example,  than  6.3  in. — we 
may  conclude  that  there  is  a  narrowing  of  the  antero-posterior  diameter 
of  the  brim,  the  extent  of  Avhich  we  must  endeavor  to  ascertain  by 
other  means. 

For  the  purpose  of  making  these  measurements  Baudelocque's  com- 
pels d'epaisseiir  can  be  used,  or  Dr.  Lazarewitch's  elegant  universal  ]3el- 
vimeter,  which  can  be  adopted  also  for  internal  pelvimetry  ;  but  in  tlie 
absence  of  these  special  contrivances  an  ordinary  pair  of  callipers,  such 
as  are  used  by  carpenters,  can  be  made  to  answer  the  desired  object. 

These  external  measurements  must  be  corroborated  by  the  internal, 
chiefly  of  the  antero-posterior  diameter,  by  which  alone  we  can  estimate 
the  amount  of  the  deformity.  We  endeavor  to  find,  in  the  first  place, 
the  length  of  the  inclined  conjugate  between  the  lower  edge  of  the  sym- 
physis pubis  and  the  promontory  of  the  sacrum,  which  averages  about 
half  an  inch  more  than   the  true  conjugate.  ^This  is  best  done  by 

I  placing  the  patient  on  her  back,  with  the  hips  well  raised.  The  index 
finger  of  the  right  hand  is  then  introduced  into  the  vagina,  and  the 
perineum  is  pressed  steadily  back-  „ 

ward,  so  as  tq  overcome  the  resist- 
ance it  offers.  If  the  tip  of  the 
finger  can  reach  the  promontory  of 
the  sacrum,  its  radial  side  is  raised 
so  as  to  touch  the  lower  edge  of 
the  pubes.  A  mark  is  made  with 
the  nail  of  the  index  of  the  left 
hand  on  that  part  of  the  examin- 
ing finger  which  rests  under  the 
symphysis,  and  then  the  distance 
from  this  to  the  tip  of  the  finger, 

.   less  half  an   inch,  may   be  taken 

1  to  indicate  the  measurement  of  the 

Vtrue  conjugate  of  the  brim.  Vari- 
ous pelvimeters  have'™been  devised 
to  make  the  same  measurements, 
such  as  Lumley  Earle's,  Lazare- 
witch's (which  is  similar  in  prin- 
ciple), and  Van  Huevel's.  The 
best  and  sim])lest,  I  think,  is  that 
invented  by  Dr.  Greenhalgh  (Fig. 
145).  It  consists  of  a  movable  rod  attached  to  the  flexible  band  of 
metal  which  passes  around  the  palm  of  the  examining  hand.  At  the 
distal  cud  of  the  rod  is  a  curved  portion,  which  passes  over  the  radial 
edge  of  the  index  finger.     The  examination  is  made  in  the  usual  way, 


Greeiilialgh's  Pelvimeter. 


400  LABOR. 

and  wIk'M  the  point  oC  the  liiiiicr  is  resting  on  tlif  j)roniontorv  ol"  the 
sjUTum,  tlic  rod  is  witlidrawn  until  it  is  ariTstod  \)\  tlic  jtostcrior  snrlace 
of  the  syiiipliysis,  the  exact  measurement  ot"  the  inelined  eoiijuj^ate  being 
then  read  ott'  the  scale. 

It  is  to  be  remembered  that  this  procedure  is  useless  in  the  slighter 
degrees  of  contraction  in  which  the  promontory  of  the  sacrum  cannot 
be  easily  reached.  Dr.  lvamsl)otham  ])ro[)osed  to  jneasure  the  c(»njugate 
bv  spreading  out  the  index  and  middle  fingers  internally,  the  tip  of  one 
resting  on  the  promontory,  the  other  behind  the  sym])liysis  |)ubis,  and 
then  drawing  them  in  the  same  position  and  measuring  the  distance 
between  them.     This  manoeuvre  I  believe  to  be  impracticable. 

Whenever,  in  actual  labor,  we  M'ish  to  ascertain  the  condition  of  the 
pelvis  accurately,  the  patient  should  l)e  aiuesthctized,  and  the  whole 
hand  introduced  into  the  vagina  (which  could  not  otherwise  be  done 
without  causing  great  pain),  and  the  proportions  of  the  pelvis  and  the 
relations  of  the  head  to  it  thoroughly  explored;  and,  if  what  has  been 
said  as  to  the  mechanism  of  delivery  in  these  cases  be  borne  in  mind, 
this  may  aid  us  in  determining  the  kind  of  deformity  existing.  In  this 
way  contractions  about  the  outlet  of  the  pelvis  can  also  be  pretty  gener- 
ally made  out. 

The  obliquely-contracted  pelvis  cannot  be  determined  by  any  of  these 
methods,  but  cerfaTrT'external  measurements,  as  Naegele  has  pointed  out, 
will  readily  enable  us  to  recognize  its  existence,  (it  will  be  found  that 
measurements  which  in  the  healthy  pelvis  ought  to  be  equal  are  unequal 
in  the  obliciuely-distorted  pelvis.  S  The  jioints  of  measurement  are 
chiefly:  (1)1  From  the  tuberosity  of  the  ischium  on  one  side  to  the 
posterior  superior  spine  of  the  ilium  on  the  other ;)  (2)  from  the  ante- 
rior superior  iliac  spine  on  one  side  to  the  posterior  superior  on  the 
opposite;  (3) 'from  the  trochanter  major  of  one  side  to  the  ])osterior 
superior  iliac  spine  on  the  other;  (4)  from  the  lower  edge  of  the  sym- 
physis pubis  to  the  posterior  superior  iliac  sj)ine  on  either  side;  (5)  from 
the  spinous  process  of  the  last  lumbar  vertebra  to  the  anterior  snjierior 
spine  of  the  ilium  on  either  side. 

If  these  measurements  diifer  from  each  other  by  half  an  inch  to  an 
inch,  the  existence  of  an  obliquely-deformed  pelvis  may  be  safely  diag- 
nosed. The  diagnosis  can  be  corroborated  by  placing  the  jiatient  in  tlie 
erect  position  and  letting  fall  two  ])lund)-lines,  one  from  the  spines  of 
the  sacrum,  the  other  from  the  symjihysis  j)ubis.  In  a  healthy  j)elvis 
these  will  fall  in  the  same  plane,  but  in  the  oblique  ])elvis  the  anterior 
line  will  deviate  consideraby  toward  the  unaffected   side. 

Treatment. — The  proper  management  of  labor  in  contracted  jielvis 
is,  even  up  to  this  time,  one  of  the  most  vexed  questions  in  midwifery, 
notwithstanding  the  immense  amount  of  discussion  to  which  it  has  given 
rise;  and  the  varying  o])inionsof  accoucheurs  of  equal  ex])erience  atlord 
a  strong  proof  of  the  difficulties  surrounding  the  subject.  This  i-emark 
a]>plies,  of  course,  only  to  the  lesser  degree  of  deformity,  in  which  the 
birth  of  a  living  child  is  not  hopeless.  When  the  antero-posterior 
diameter  of  the  brim  measures  from  2J  to  3  inches,  it  is  universally 
admitted  that  the  destruction  of  the  child  is  inevitable,  unless  the  ])elvis 
be  so  small  as  to  necessitate  the  performance  of  the  Ca?sarean  section. 


DEFORMITIES  OF  THE  PELVIS.  401 

But  when  it  is  between  3  inelies  and  tlie  normal  measurement  tlie  com- 
parative merits  of  the  tbrcej)S,  turning,  and  the  induction  of  premature 
labor  foriu  a  fruitful  theme  for  discussion.  With  one  class  of  accouch- 
eurs the  force])s  is  chietiy  advocated,  and  turning  admitted  as  an  occa- 
sional resource  when  it  has  failed;  and  this  indeed,  speaking  broadly, 
may  be  said  to  have  been  the  general  view  held  in  England.  j\Iore 
recently  we  find  German  authorities  of  eminence,  such  as  Schroeder  and 
Spiegelbei'g,  giving  turning  the  chief  place,  and  condemning  the  forceps 
altogether  in  (jontractcd  })elves,  or  at  least  restricting  its  use  within  very 
narrow  limits.  More  strangely  still,  we  find,  of  late,  that  the  induction 
of  premature  labor,  on  the  origination  and  extension  of  which  British 
accoucheurs  have  always  prided  themselves^  is  placed  without  the  pale 
and  spoken  of  as  injurious  and  useless  in  reference  to  pelvic  deformities. 
To  see  our  way  clearly  amongst  so  many  conflicting  opinions  is  by  no 
means  an  easy  task,  and  perhaps  we  may  best  aid  in  its  accomplishment 
by  considering  separately  the  three  operations  in  so  far  as  they  bear  on 
this  subject,  and  pointing  out  briefly  what  can  be  said  for  and  against 
each  of  them. 

The  Forceps. — In  England  and  in  France  it  is  pretty  generally 
admitted  that  in  the  slighter  degrees  of  contraction  the  most  reliable 
means  of  aiding  the  patient  is  by  the  forceps.  It  should  be  remembered 
that  the  operation  under  such  circumstances  is  always  much  more  serious 
than  in  ordinary  labors  simply  delayed  from  uterine  inertia,  when  there 
is  ample  room  and  the  head  is  in  the  cavity  of  the  pelvis ;  for  the  blades 
have  to  be  passed  up  very  high,  often  when  the  head  is  more  or  less 
movable  above  the  brim,  and  much  more  traction  is  likely  to  be  required. 
VFor  these  reasons  artificial  assistance  when  pelvic  deformity  is  suspected 
is  ]iot  to  be  lightly  or  hurriedly  resorted  to.  )  Nor,  fortunately,  is  it 
always  necessary,  for  if  the  pains  be  sufficiently  sti^ong  and  the  con- 
traction not  too  great  to  prevent  the  head  engaging  at  all,  after  a  lapse 
of  time  it  will  become  so  moulded  in  the  brim  as  to  pass  even  a  con- 
siderable obstruction.  In  all  cases,  therefore,  sufficient  time  must  be 
given  for  this ;  and  if  no  suspicious  symptoms  exist  on  the  part  of  the 
mother — no  elevation  of  temperature,  dryness  of  the  vagina,  rapid  pulse, 
and  the  like,  and  the  fostal  heart-sounds  continue  to  be  normal — labor 
may  be  allowed  to  go  on  for  some  hours  after  the  rupture  of  the  mem- 
branes, so  as  to  give  nature  a  chance  of  completing  the  delivery.  When 
this  seems  hopeless  the  intervention  of  art  is  called  for. 

The  forceps  is  generally  considered  to  be  applicable  in  all  degrees  of 
contraction  from  the  standard  measurement  down  to  about  3^  inches  in 
the  conjugate  of  the  brim.  There  can  be  no  doubt  that  in  such  cases 
traction  with  the  forceps  often  enables  us  to  effect  delivery  when  the 
natural  efforts  have  proved  insufficient,  and  holds  out  a  very  fair  hope 
of  saving  the  child.  Out  of  17  cases  in  which  the  high-forceps  opera- 
tion M'as  resorted  to  for  pelvic  deformity,  reported  by  Stanesco,  in  13, 
living  children  were  born.  If  the  length  of  tlie  labor  and  the  long- 
continued  compression  to  which  the  child  has  been  subjected  be  borne  in 
mind,  this  result  must  be  considered  very  favorable. 

What  are  the  objections  which  have  been  brought  against  the  opera- 
tion ■?     These  have  been  principally  made  by  Schroeder  and  other  Ger-  ,      j^ 


402 


LABOR. 


man  writers.  Tlicv  arc,  cliitlly,  the  difficulty  of  passiii<]j  tlic  iiistrunient, 
the  risk  o{  injuring  the  inalcnial  sti'iictnrcs,  and  the  siqipositioii  that,  as 
till'  hladt's  iiuist  seize  the  head  l)y  the  loi'clicad  and  ciccipnt,  their  eoin- 
jtressive  action  will  diminish  its  lonj^itudinal  and  incivase  its  transverse 
diameter  (whieii  is  opj)osed  to  the  contracted  part  of  the  brim),  and  so 
enlarge  the  head  just  where  it  ought  to  be  smallest.  Tliere  is  little 
doubt  that  these  writers  much  exaggerate  the  compressive  ])ower  of 
the  force])s.  CVrlainly,  with  the  forms  generally  used  in  England  any 
disadvantage  likely  to  accrue  from  this  is  more  than  countei'balaneed 
by  the  traction  of  the  head  ;  and  the  fact  that  minor  degrees  of 
obstruction  can  be  thus  overcome  with  safety  both  to  the  mother  and 
child  is  abundantly  proved  by  tlie  uumberless  cases  in  which  the  for- 
ceps has  been  used. 

It  is  very  likely  that  the  forceps  does  not  act  e(pially  well  in  all  ca.ses. 
C^Vlien  the  head  is  loose  above  the  brim;  when  the  contraction  is  chiefly 
limited  to  the  antero-posterior  diameter,  and  there  is  abundance  of  room 
at  the  sides  of  the  pelvis  for  the  occiput  to  occupy  after  version ;  and 
when,  as  is  usual  in  these  cases,  the  anterior  fontiuielle  is  depressed  and 
ithe  head  lies  transversely  across  the  brim, — it  is  probable  that  turning 
may  be  the  safer  operation  for  the  mother,  and  the  easier  pcrformetD 
AVhen,  on  the  other  hand,  the  head  has  engaged  in  the  brim  and 
lias  become  more  or  less  impacted,  it  is  obvious  that  version  could 
not  be  performed  without  pushing  it  back,  which  may  be  neither  easy 
nor  safe.  In  the  generally-contracted  j^elvis,  in  which  the  head  enters 
in  an  exaggerated  state  of  flexion  and  lies  obliquely,  the  posterior 
fontauelle  being  much  depressed,  the  forceps  is  more  suitable. 

Mechanical  Advantage  of  Turning  in  Certain  Cases. — The 
special  reasons  why  version  sometimes  succeeds  when  the  forceps 
fails,  or  why  it  may  be  elected  from  the  first  as  a  matter  of  choice, 
have  been  by  no  one  better  pointed  out  than  by  Sir  James  Simpson. 
Although  the  operation  was  performed  by  many  of  the  older  obstetri- 


FiC4.  146. 


Fto. 147, 


Section  of  Fcetal  Cranium,  showing  its 
conical  I'orm 


Showing  llu'  iJri'aicr  Rrcadlh  of  the 
IJiparictal  liiaincter  of  the  Fcetal 
Cranium.     (After  Simpson.) 


ciaus,  its  revival  in  modern  times  and  the  clear  enunciation  of  its  princi- 
ples can  undoubtedly  be  traced  to  his  writings.  He  points  out  that  the 
head  of  a  child  is  .shaped  like  a  cone  its  narrowest  portion  the  ba.se  of  the 


DEFORMITIES  OF  THE  FELVIS.  403 

cranium  (Fig.  146,  h  b),  ineasiiriiig,  on  an  average,  from  -|  to  f  of  an 
inch  less  than  the  broadest  portion  (Fig.  146,  a  a) — viz.  the  biparietal 
diameter.  In  ordinary  head  presentations  the  latter  part  of  the  head 
has  to  pass  first;  but  if  the  feet  are  brought  down,  the  narrow  apex  of 
the  cranial  cone  is  brought  first  into  ai)])osition  with  tlie  contracted  brim, 
and  can  be  more  easily  drawn  tiirough  than  the  broader  base  can  be 
pushed  tiirough  by  the  uterine  contractions.  Nor  is  this  the  only  advan- 
tage, for  after  turning  the  narrower  bitemporal  diameter  (Fig.  147,  b  b) 
— which  measures,  on  an  average,  half  an  inch  less  than  the  biparietal 
(Fig.  147,  a  a) — is  brought  into  contact  with  the  contracted  conjugate, 
wliile  the  broader  biparietal  lies  in  the  comparatively  wide  space  at  the 
side  of  the  pelvis  (Fig.  148).     These  mechanical  considerations  are 

Fig.  148. 


Showing  the  Greater  Space  for  the  Biparietal  Diameter  at  the  side  of  the  pelvis  in  certain  cases 
of  deformity.    (After  Simpson.) 

sufficiently  obvious,  and  fully  explain  the  success  which  has  often 
attended  the  performance  of  the  operation. 

It  is  generally  admitted  that  it  may  be  possible,  for  the  reasons  ju.st 
mentioned,  to  deliver  a  living  child  by  turning  through  a  pelvis  con- 
tracted beyond  tlie  point  which  would  permit  of  a  living  child  being 
extracted  by  the  forceps.  Many  obstetricians  believe  that  it  is  possible 
to  deliver  a  living  child  by  turning  in  a  pelvis  contracted  even  to  the 
extent  of  2f  inches  in  the  conjugate  diameter.  Barnes  maintains  that, 
although  an  unusually  compressible  head  may  be  drawn  through  a  pel- 
vis contracted  to  3  inches,  the  chance  of  the  child  being  born  alive  under 
such  circumstances  must  necessarily  be  small,  and  that  from  3j  inches 
to  the  normal  size  must  be  taken  as  the  proper  limits  of  the  operation. 

That  delivery  is  often  possible  by  turning  after  the  forceps  and  the 
natural  powers  have  failed,  and  wliennoother  resource  is  left  but  the 
destruction  of_ihej;Jjild,  mu.st,  I  think,  be  admitted  by  all,  for  the 
records  ot  obstetrics  are  full  of  such  cases.  To  take  one  example  only : 
Dr.  Braxton  Hicks  ^  records  4  cases  in  which  the  forceps  was  tried 
unsuccessfully,  in  all  of  which  version  was  used,  3  of  the  children  being 
born  alive.  Here  are  the  lives  of  three  children  rescued  from  destruc- 
tion within  a  short  period  in  the  practice  of  one  man  ;  and  a  fact  like 
this  would  of  itself  be  ample  justification  of  the  attempt  to  deliver  by 
turning  when  the  child  was  known  to  be  alive  and  other  means  had 
failed.  The  possibility  that  craniotomy  may  still  be  required  is  no 
^  Gin/s  Hospital  Beports,  1870. 


4U4  LABOli. 

artriinK'nt  against  the  ojicration  ;  for  altlif)ui!:h  jiorforatioji  of  tho  aftcr- 
coiuiiii;'  head  is  certainly  not  so  casv  as  pci'loratioii  of"  a  j)rt'sc'iitin<i;  licad, 
it  is  not  so  nuicli  nioiv  dillicnlt  as  to  jnstify  tho  nc<rlcct  of  an  cxperi- 
jnont   by  wliidi   it   may  jxtssibly  he  altogether  avoided. 

The  original  ehoioe  of"  turning  is  a  more  diflieult  question  to  decide. 
The  most  generally  received  opinion  in  the  present  day  among  scientific 
obstetricians  is  that  in  the  simply  fiattened  pelvis,  with  an  antero-poste- 
rior  diameter  of  not  less  than  2|  inches,  turning  is  the  ])ref"eral)le  ope- 
ration. In  eveiy  case  of"  doubt  it  is  desirable  thoroughly  to  anjicsthetize 
the  i)atient  and  make  a  careful  examination  with  the  M'liole  hand  in  the 
vagina.  If  we  find  the  sagittal  suture  lying  transversely,  one  j)arietal 
bone  on  a  lower  line  than  the  other,  and  if  both  fontanelles  are  easily 
within  reach,  and  some  space  exists  at  the  sides  of  the  pelvis  beside  the 
forehead  and  occiput,  then  turning  is  the  procedure  most  likely  to  suc- 
ceed, and  the  descent  of  the  liead  after  version  can  l)e  very  matei-ially 
assisted  by  strong  pressure  ajjplied  from  above  by  an  assistant,  as  has 
been  well  j)ointed  out  by  Goodell.^  If,  on  the  other  hand,  the  anterior 
foutanelle  is  high  up  and  out  of  reach,  the  head  being  distinctly  flexed, 
we  have  to  do  with  a  generally-contracted  pelvis  and  the  forceps  is  the 
preferable  operation. 

AA'hen  the  contraction  is  below  3  inches  in  the  conjugate,  or  when  the 
forceps  and  turning  have  failed,  no  resource  is  left  but  the  destruction 
of  the  foetus  or  the  CVesarean  section. 

The  Induction  of  Premature  Labor. — The  induction  of  premature 
labor  as  a  means  of  avoiding  the  risks  of  delivery  at  term,  and  of  possi- 
bly saving  the  life  of  the  child,  must  now  be  studied.  rThe  established 
rule  in  England  is,  that  in  all  cases  of  pelvic  deformity  the  existence 
of  which  has  been  ascertained  either  by  the  experience  of  former  labors 
or  by  accurate  examination  of  the  pelvis,  labor  should  be  induced  })re- 
vious  to  the  full  period,  so  that  the  smaller  and  more  compressible  head 
of  the  premature  foetus  may  pass  where  that  of  the  fa^tus  at  term  could 
uot.\  (The  gain  is  a  double  one — partly  the  lessened  risk  to  the  mother, 
and  'partly  the  chance  of  saving  the  child's  life.) 

The  practice  is  so  thoroughly  recognized  as  a  conservative  and  judici- 
ous one  that  it  might  be  deemed  unnecessary  to  argue  in  its  favor,  ^\"ere 
it  not  that  some  eminent  authorities  have  of  late  years  tried  to  show  that 
it  is  better  and  Siifer  to  the  mother  to  leave  the  labor  to  come  on  at  term, 
and  that  the  risk  to  the  child  is  so  great  in  artificially  induced  labor 
as  to  lead  to  the  conclusion  that  the  operations  should  be  alt(»gether 
abandoned,  except,  perhaps,  iii  the  extreme  distoi'tion  in  which  the 
C'lesarean  section  might  otherwise  be  necessary.  Prominent  amongst 
those  who  hold  these  views  are  Spiegelberg  and  Litzmann,  and  they  have 
been  supported  in  a  modified  form  by  Matthews  Duncan.  Spiegelberg* 
tries  to  show,  l)y  a  collection  of  cases  from  various  sources,  that  the 
results  of  induced  labor  in  contracted  pelvis  are  much  more  unfavorable 
than  M'hen  the  cases  are  left  to  nature — that  in  the  latter  the  mortality 
of  the  mothers  is  6.6  per  cent,  and  of  the  children  28.7  per  cent., 
whereas  in   the  former  the  maternal  deaths  are  15  per  cent,  and  the 

'  Amer.  Joiini.  of  Ohtet.,  1875-76,  vol.  viii.  y.  193. 

"  Arch./.  Gyn.,  1870,  Bd.  i.  S.,  1  :  ''  Ueber  den  Wertli  der  kuntslidieii  Fruhgeburt.'* 

a.6    3,  '  ss'i 


DEFORMITIES   OF  THE  PELVIS.  405 

inihntilc  ()6.9  per  cent.  Jjitziiianii '  iirrives  at  not  very  dissimilar  re- 
sults— namely,  0.9  per  cent,  of  the  mothers  and  20.3  per  cent,  of  the  chil- 
dren in  contracted  pelves  at  term,  and  14.7  ])cr  cent,  of  the  mothers  and 
55.8  per  cent,  of  the  children  in  artificially  induced  [)r('niatnre  labor. 

If  these  statistics  were  reliable,  inasmucli  as  they  show  a  veiy  decided 
risk  to  the  mother  there  might  be  great  fc^rce  in  the  argument  that  it 
■would  be  better  to  leave  the  cases  to  run  the  chance  of  delivery  at 
term.  It  is,  however,  very  questionable  whether  they  can  be 
taken,  in  themselves,  as  being  sufficient  to  settle  the  question.  The  fal- 
lacy of  determining  such  points  by  a  mass  of  heterogeneous  cases,  col- 
lected together  without  a  careful  sifting  of  their  histories,  has  over  and 
over  again  been  pointed  out ;  and  it  would  be  easy  enough  to  meet  them 
by  an  equal  catalogue  of  cases  in  which  the  maternal  mortality  is  almost 
nil.  The  results  of  the  jjractice  of  many  authorities  are  given  in 
Churchill's  work,  where  we  find,  for  example,  that  out  of  46  cases  of 
Merri man's,  not  one  proved  fatal.  The  same  fortunate  result  happened 
in  62  cases  of  Ramsbotham's.  His  conclusion  is  that  "  there  is  undoubt- 
edly some  risk  incurred  by  the  mother,  but  not  more  than  by  accidental 
premature  labor ;"  and  this  conclusion  as  regards  the  mother  is  that 
M'hich  has  long  ago  been  arrived  at  by  the  majority  of  British  obstetri- 
cians, who  undoubtedly  have  more  experience  of  the  operation  than 
that  of  any  other  nation.  With  regard  to  the  child,  even  if  the  Ger- 
man statistics  be  taken  as  reliable,  they  would  hardly  be  accepted  as 
contraindicating  the  operation,  inasmuch  as  it  is  intended  to  save  the 
mother  from  the  dangers  of  the  more  serious  labor  at  term,  and  in  many 
cases  to  give  at  least  a  chance  to  the  child,  whose  life  would  otherwise 
be  certainly  sacrificed.  The  result,  moreover,  must  depend  to  a  great 
extent  on  the  method  of  operation  adopted,  for  many  of  the  plans  of 
inducing  labor  recommended  are  certainly,  in  themselves,  not  devoid  of 
danger  both  to  the  mother  and  the  child.  It  may,  I  think,  be  admit- 
ted, as  Duncan  contends,  that  the  operation  has  been  more  often  per- 
formed than  is  absolutely  necessary,  and  that  the  higher  degrees  of 
pelvic  contraction  are  much  more  uncommon  than  has  been  supposed  to 
be  the  case.  That  is  a  very  valid  reason  for  insisting  on  a  careful  and 
accurate  diagnosis,  but  not  for  rejecting  an  operation  which  has  so  long 
been  an  established  and  favorite  resource. 

Inches.         Lines. 
When  tlie  sacro-pubic  diameter  is  2  and    6  or    7,  induce  labor  at  30th  week. 


2  " 

8  "  9, 

"  31st 

2  " 

■     10  "  11, 

"  32d 

3  " 

— 

"  33d 

3  " 

1. 

"  33d 

3  " 

'   2  or  3, 

"  34th 

3  " 

4  "  5, 

"  ooth 

3  " 

5  "  6, 

"  36th 

When  the  induction  of  labor  has  been  determined  on,  the  precise 
period  at  which  it  should  be  resorted  to  becomes  a  question  for  anxious 
consideration,  since  the  longer  it  is  delayed  the  greater,  of  course,  are 
the  dangers  for  the  child.     Many  tables  have  been  constructed  to  guide 

1  Arch.  f.  Gyn.,  1873,  Bd.  ii.  S.  109  :  "  Ueber  den  Werth  dor  kiinstlichen  Friihgeburt." 


406  LABOR. 

us  on  this  jH)iiit,  wliicli  are  not,  on  the  wliole,  of  so  nuicli  service  as 
tliev  inig,lit  apjicar  to  he,  on  account  of"  the  difficulty  ol"  deterniining 
with  niimite  accuracy  the  amount  of  contraction.  Tlie  ])rece(lijig  tahlo, 
lu»\vever,  which  is  drawn  up  by  Kiwisch,  may  serve  for  a  guide  in 
settling  this  question. 

In  cases  of  moderate  deformity,  wlicn  labor-pains  have  been  induced, 
the  further  progress  of  the  case  may  l)e  left  to  nature;  l)ut  in  more 
marked  cases,  as  in  those  below  3  inches,  it  will  often  be  found  neces- 
sary to  assist  delivery  by  turning  or  by  the  forcejjs,  the  former  being 
here  especially  useful,  on  account  of  the  extreme  pliability  of  the  head 
and  the  facility  with  which  it  may  be  drawn  through  the  contracted 
brim.  By  thus  combining  the  two  operations  it  may  be  quite  ])Ossible 
to  secure  the  birth  of  a  living  child  even  in  pelves  very  considerably 
detbrmed. 

Production  of  Abortion  in  Extreme  Deformity. — A\'hcn  the  con- 
traction is  so  great  as  to  necessitate  the  induction  of  the  labor  before 
the  sixth  month — or,  in  other  words,  before  the  child  has  reached  a 
viable  age — it  would  be  preferable  to  resort  to  a  very  early  production 
of  abortion.  (The  operation  is  then  indicated,  not  for  the  sake  of  the 
child,  but  to  save  the  mother  from  the  deadly  risk  to  which  she  Mould 
otherwise  be  subjected.^  As  in  these  cases  the  mother  alone  is  concerned, 
the  operation  should  be  performed  as  soon  as  we  have  positively  deter- 
mined the  existence  of  pregnancy.  No  object  can  be  gained  by  waiting 
until  the  development  of  the  child  is  advanced  to  any  extent,  and  the 
less  the  fretus  is  developed  the  less  will  be  the  pain  and  risks  the  mother 
has  to  undergo.  There  is  no  amount  of  deformity,  however  great,  in 
Mhich  we  could  not  succeed  in  bringing  on  miscarriage  by  some  of  the 
numerous  means  at  our  disposal ;  and  in  spite  of  Dr.  Radford's  objec- 
tions, Avho  maintains  that  the  obstetrician  is  not  justified  in  sacrificing 
the  life  of  a  human  being  more  than  once  when  the  mother  knows 
that  she  cannot  give  birth  to  a  viable  child,  there  are  few  ])ractitionei*s 
W'ho  would  not  deem  it  their  duty  to  spare  the  mother  the  terrible 
dangers  of  the  Csesarean  section. 

[This  opinion,  by  reason  of  remarkable  successes  during  the  last  four 
years,  has  much  less  weight  than  it  was  entitled  to  a  few  yeai*s  ago. 
The  views  of  anti-Cfesareauists  in  England  are  largely  due  to  Nvant 
of  success  at  home ;  and  this  want  of  success  will  continue  until  the 
operation  is  undertaken  with  greater  ])romptness  and  with  a  confidence 
ba.scd  upon  continental  opinions  and  results.  AVe  are  now  in  this 
country  adopting  German  rather  than  British  views  upon  gastro-hys- 
terotomy,  and  as  a  result,  especially  in  our  cities  and  maternity  hos- 
pitals, are  largely  diminishing  the  proportion  of  deaths.  Prof  V^w\. 
Goodell  showed  his  confidence  in  asepsis  and  the  conservative  method 
recently,  by  operating  in  a  general  hospital  In'tbre  a  class  of  five  hundred 
students  :  the  woman  did  well  and  the  child  lived.  The  ca.<e  was  one 
of  cancer,  which  proved  fatal  from  sudden  hemorrhage  on  the  twenty-' 
sixth  day  ;  after  the  wounds  produced  by  the  section  had  entirely  healed, 
the  cancerous  ulceration  having  opened  an  im])ortant  blood-vessel.  The 
last  five  Ctcsarean  ojierations  in  tlie  city  of  Philadeljihia  have  all  been 
successful  (April,  1888,  to  May,  1889,  "inclusive).— Ed.] 


HEMORRUALIE  BEFORE  DELIVERY.  407 


CHAPTER    XIII. 

HEMORRHAGE  BEFORE  DELIVERY:   PLACENTA  PREVIA. 

The  hemorrhages  Mhich  arc  the  result  of  an  abnormal  situation  of 
the  placenta,  ])artiallv  or  entirely,  over  the  internal  os  uteri  have  formed 
a  most  fruitful  theme  for  discussion.  The  explanation  of  the  abnormal 
placental  site,  the  sources  of  the  blood,  and  the  causes  of  its  escape,  the 
means  adopted  by  nature  for  its  arrest,  and  the  proper  treatment,  have, 
each  and  all  of  them,  l)een  the  subject  of  endless  controversies  which 
are  not  yet  by  any  means  settled.  It  must  be  admitted,  too,  that  the 
extreme  importance  of  the  subject  amply  justifies  the  attention  which 
has  been  paid  to  it ;  for  there  is  no  obstetric  complication  more  apt  to 
produce  sudden  and  alarming  effects,  and  none  requiring  more  prompt 
and  scientific  treatment. 

Definition. — By  placenta  pnevia  we  mean  the  insertion  of  the  pla-  ) 
centa  at  the  lower  segment  of  the  uterine  cavity,  so  that  a  portion  of 
it  is  situated,  wholly  or  partially,  over  the  internal  os  uteri.     In  the 
former  case  there  is  complete  or  central  placental  presentation,  in  the  : 
latter  an  incomplete  or  marginal  presentation. 

Causes.— rThe  causes  of  this  abnormal  placental  site  are  not  fully 
understood,  t  It  was  supposed  by  Tyler  Smith  to  depend  on  the  ovule 
not  having  been  impregnated  until  it  had  reached  the  lower  part  of 
the  uterine  cavit}^  \  Cazeaux  suggests  that  the  uterine  mucous  mem- 
brane is  less  swollen  and  turgid  than  w^hen  impregnation  occurs  at  the 
more  ordinary  place,  and  that  therefore  it  offers  less  obstruction  to  the 
descent  of  the  ovule  to  the  lower  part  of  the  uterine  cavity^  An  abnor- 
mal  sjze  or  unusual  shape  of  the  uterine  cavity  may  also  favor  the 
descent  of  the  impregnated  ovule;  the  former  probably  explains  the 
fact  that  placenta  prsevia  more  generally  occurs  in  women  who  have 
alixiadybonie  children.  Miiller  believes  that  it  results  from(iiterine 
contractions  occurring  shortly  after  conception,  which  force  the  ovrfm 
do\vn  to  the  lower  part  of  the  uterine  cavity'i  These  ate  merely  inter- 
esting speculations  having  no  practical  value,  the  fact  being  undoubted 
that  in  a  not  inconsiderable  number  of  cases — estimated  by  Johnson 
and  Sinclair  as  1  out  of  573 — the  placenta  is  grafted  partially  or 
entirely  over  the  uterine  orifice,  although  it  is  now  generally  admitted 
that  the  placenta  is  never  attached  to  any  portion  of  the  cervix  itself. 

History. — Placenta,  prasvia  was  not  unknown  to  the  older  writers, 
Avho  believed  that  the  placenta  had  originally  been  situated  at  the 
fundus,  from  which  it  had  accidentally  fallen  to  the  lower  part  of  the 
uterus.  Portal,  Levret,  Roederer,  and  especially  the  British  author 
Rigby,  were  among  those  M'liose  observations  tended  to  improve  the 
state  of  obstetrical  knowledge  as  to  its  real  nature.  To  Rigby  we  owe 
the  term  '»' unavoidable  hemorrhage"  as  a  synonym  for  placenta  ])rwvia, 
and  as  distinguishing  hemorrhage  from  this  source  from  that  resulting 


408  LABOR. 

from  so]>arati(>n  of  tlip  ]>lacenta  at  its  more  usual  position,  termetl  by 
him,  in  c-outradistinctictii,  '*  acfidcntul  liC'morriia<rc'."  These  means, 
a(h)j)tecl  hy  most  writers  on  the  suhjeet,  are  ohvi(jusly  misleading,  as 
they  assume  an  essential  distinction  in  the  etiolojry  of  the  hemon-hage 
in  the  two  classes  of  cases  which  is  not  always  warranted. 

It  is  of  the  utmost  importance  to  a  right  understanding  of  the  nature 
and  treatment  of  placenta  prtvvia  that  we  should  fully  undei-stand  the 
source  of  the  hemori-hage  and  the  manner  of  its  j)roduction  ;  hut  we 
shall  be  al)le  to  discuss  this  subject  better  after  a  descri})tion  of  the 
symptoms. 

Symptoms. — Although  the  placenta  must  occupy  its  unusual  site 
from  the  earliest  period  of  its  formation,  it  girelv  gives  rise  to  a])preci- 
able  symptoms  before  the  last  three  months  of  utcro-gestation.  (it  is  far 
from  unlikely,  however,  that  such  an  abnormal  situation  of  the  j)lacenta 
may  produce  abortion  in  the  earlier  months,  the  site  of  its  attachment 
passing  iniobserved.\ 

The  earliest  symjxom  which  causes  suspicion  is  the  sudden  occurronce 
of  liemorrhage  without  any  appreciable  cause.  (The  amount  of  blootl 
lost  varies  considerably)  In  some  cases  the  first  hemorrhage  is  com- 
})aratively  slityht,  and  is  soon  spontaneously  arrested  ;  but  if  the  case 
be  left  to  itself  the  flow  after  a  lapse  of  time — it  may  be  a  few  days 
or  it  may  be  ^veeks — again  commences  in  the  same  unexpected  way, 
and  each  successive  hemorrhage  is  more  profuse.  The  losses  show 
themselves  at  different  periods.  They  rarely  begin  before  the  end  of 
the  sixth  month,  more  often  nearer  the  full  period,  and  sometimes  not 
until  labor  has  actually  commenced.  /The  hemorrhage  is  said,  but 
tlij_s  is  doubtful,  to  often  coincide  with  what  Avould  have  been  a  men- 
strual j)eriod,  possibly  on  account  of  the  physiological  congestion  of 
the  uterine  organs  then  present.  /Should  the  first  loss  not  show  itself 
until  at  or  near  tiie  full  time,  it  Jirav  be  tremendous,  and  a  few  moments 

imay  suffice  to  place  the  patient's  life  in  jeopardyj  Indeed,  it  may  be 
safely  accepted  as  an  axiom,  that  once  hemorrlwge  has  occurred  the 
patient  is  never  safe ;  for  excessive  losses  may  occur  at  any  moment 
^vithout  warning  and  when  assistance  is  not  at  hand.  It  often  hap- 
pens that  premature  labor  comes  on  after  one  or  more  hemorrhages. 
^In  any  case  of  placenta  prsevia,  when  labor  has  commenced,  whether 
premature  or  at  the  full  time,  the  hemorrhage  may  become  excessive, 
and  with  each  ])ain  fresh  portions  of  placenta  may  be  detached  and  fresh 
vessels  torn  and  left  open.)  Under  these  circumstances  the  blood  often 
escapes  in  greater  quantity  with  each  successive  pain,  and  diminishes  in 
the  interval.  This  has  long  been  looked  upon  as  a  diagnostic  mark  l)y 
which  we  can  distinguish  between  the  so-called  "  unavoidable "  and 
"accidental"  hemorrhage,  in  the  latter  the  flow  being  arrested  during 
the  pains.  The  distinction,  however,  is  altogether  fidlacious.  The  tend- 
ency of  uterine  contraction  in  placenta  pra?via,  as  in  all  other  forms  of 
uterine  hemorrhage,  is  to  constrict  the  vessels  fi-om  Tvhich  the  blood 
escapes,  and  so  to  lessen  the  flow.  (1^\\q  apparently  increased  flow  dur- 
ing the  pains  depends  on  the  i)ains  forcing  out  blood  which  has  already 
escaped  from  the  vessels.j|  (In  one  way,  up  to  a  certain  point,  the  pains 
do  favor  hemorrhage  by  detaching  fresh  portions  of  placenta  ;  but  the 


HEMORRHAGE  BEFORE  DELIVERY.  409 

actual  loss  takes  pkuic  (thiofly  during  the  intervals,  and  not   during  the 
coutinuanee  of  coutraetioii.'^ 

()ii_vaj^'iiial  cxniiiiiiation,  if  the  os  be  suflici(,'ntly  o})en  to  admit  the 
finger — whicli  it  uonerally  is  on  account  of  the  relaxation  produced  by 
the  loss  of  blood — we  shall  almost  always  be  able  to  feel  some  portion 
of  presenting  placenta.  ^  If  it  be  a  central  implantation,  we  shall  find 
the  aperture  of  the  cervix  entirely  covered  by  a  thick,  boggy  mass, 
which  is  to  be  distinguished  from  a  coagulum  by  its  consistence  and  by 
its  not  breaking  down  under  the  pressure  of  the  finger.  Through  the 
placental  mass  we  may  feel  the  presenting  part  of  the  foetus,  but  not  as 
distinctly  as  when  there  is  no  intervening  substance^  /In  partial  placen- 
tal presentation  the  bag  of  membranes,  and  above  it  the  head  or  other 
presentations,  will  be  found  to  occupy  a  })art  of  the  circle  of  the  os,  the 
rest  being  covered  by  the  edge  of  the  placenta.  In  marginal  presenta- 
tions we  may  only  be  able  to  make  out  the  thickened  edge  of  the  after- 
birth projecting  at  the  rim  of  the  os."\  If  the  cervix  be  high  and  tlie 
gestation  not  advanced  to  term,  these  points  may  not  be  easy  to  make 
out  on  account  of  the  difficulty  of  reaching  the  cervix  ;  and,  as  accurate 
diagnosis  is  of  the  utmost  importance,  it  is  proper  to  introduce  two  fin- 
gers, or  even  the  whole  hand,  so  as  thoroughly  to  explore  the  condition 
of  the  parts.  The  lower  portion  of  the  uterine  ovoid  may  be  observed 
to  be  more  than  usually  thick  and  fleshy  ;  and  Gendrin  has  pointed  out 
that  ballottement  cannot  be  made  out.  (.The  accuracy  of  our  diagnosis 
may  be  confirmed  in  doubtful  cases  by  finding  that  the  placental  bruit 
is  heard  over  the  lower  part  of  the  uterine  tumor.^  '      ' 

Dr.  Wallace  ^  has  suggested  that  vaginal  auscultation  may  be  service- 
able in  diagnosis,  and  states  that  by  means  of  a  curved  wooden  stetho- 
scope the  placental  bruit  may  be  heard  with  startling  distinctness.  This 
is,  however,  a  manoeuvre  that  can  hardly  be  generally  carried  out  in- 
actual  practice. 

(It  is  now  generally  admitted  by  authorities  that  the  immediate  source 
of\he  hemorrhage  is  the  lacerated  uter(j-placental  vessels^  Only  a  few 
years  ago  Sir  James  Simpson  advocated,  Avitli  his  usual  energy,  the 
theory  sustained  by  his  predecessor.  Dr.  Hamilton,  that  the  chief  if  not 
the  only  source  of  hemorrhage  was  the  detached  portion  of  the  placenta 
itself.  He  argued  that  the  blood  flowed  from  the  portion  of  the  pla- 
centa Avhich  was  still  adherent  into  that  which  was  separated,  and 
escaped  from  the  surface  of  the  latter ;  and  on  this  supposition  he  based 
his  practice  of  entirely  separating  the  placenta,  having  observed  that  in 
many  cases  in  which  the  after-birth  had  been  expelled  before  the  child 
the  hemorrhage  had  ceased.  (  The  fixct  of  the  cessation  of  the  hemor- 
rhage when  this  occurs  is  not  doubted  \  but  Simpson's  explanation  is 
contested  by  most  modern  writers,  prominent  among  whom  is  Barnes, 
who  has  devoted  much  study  to  the  elucidation  of  the  subject.  '  He 
])oiuts  out  that  the  stoppage  of  the  hemorrhage  is  not  due  to  the  separa- 
tion of  the  placenta,  but  to  the  preceding  or  accompanying  contraction 
of  the  uterus,  which  seals  up  the  bleeding  vessels,  just  as  it  does  in  other 
forms  of  hemorrhage.:  The  site  of  the  loss  was  actually  demonstrated 
by  the  late  Dr.  INIackenzie  in  a  series  of  exiieriments,  in  which  he  pai'- 

^  Edin.  Med.  Journ.,  vol.  1872-73,  p.  427. 


II 


410  LMinii. 

tially  detached  tlio  placenta  in  prerrnaiit  bitclies,  and  foniid  tlmt  the 
Mood  flowed  from  the  walls  oi"  the  uterus,  and  not  from  the  detached 
sui'f'ace  of"  the  j)hicenta.  'I'he  ai'ran<;ement  of  the  lar^e  venous  sinuses, 
opening  as  they  do  on  the  uteiMue  mucous  memhraiic,  favors  the  escaj)e 
of  blood  when  they  are  torn  across ;  and  it  is  from  them,  possibly  to 
some  extent  also  from  the  uterine  arteries,  that  the  blood  comes,  just  as 
in  post-])artum  hemorrhage,  when  the  whole  instead  of  a  part  of  the 
])lacental  site  is  bared. 

A'^arious  explanations  have  been  given  of  the  causes  of  the  hemor- 
rhage. (y^Y  long  it  was  supposed  to  (le[)end  on  the  gradual  ex])ansi<»n 
of  the  cervix  during  the  latter  months  of  pregnancy,  which  separated 
the  abnormally  placed  placenta.N  (it  has  been  seen,  however,  that  this 
shortening  of  the  cervix  is  apparent  oply,  and  that  the  cervical  canal  is 
not  taken  up  into  the  uterine  cavity  during  gestation,  or,  at  all  events, 
onlv  durinu:  the  last  week  or  so.  This,  therefore,  cannot  be  admitted 
as  an  ex])lanation  of  placental  separation.  vJaccjiiemk'r  ])roposed  another 
theory,  which  has  been  adopted  by  Cazeaux.  He  maintains  that  during 
the  first  six  mouths  of  utero-gestation  the  superior  portion  of  the  uterus 
is  more  especially  developed,  as  shown  by  the  pyriform  shape  of  the 
fundus  during  the  time,  and  that,  as  the  placenta  is  usually  attached  in 
that  situation  and  then  attains  its  maximum  of  development,  its  rela- 
tions to  its  attachments  are  undisturbed.  During  the  last  three  months 
of  pregnancy,  on  the  contrary,  the  lower  segment  of  the  uterus  develops 
more  than  the  upper,  while  the  placenta  remains  nearly  stationary  in 
size  ;  the  inevitable  result  being  a  loss  of  proportion  between  the  cervix 
and  the  placenta,  and  the  detachment  of  the  latter,f'  There  are  various 
objections  which  can  be  brought  against  this  theory,  the  most  impoi'tant 
beino;  that  there  is  no  evidence  at  all  to  show  that  the  lower  segment  of 
the  uterus  does  expand  more  in  projiortion  than  the  upjK'r  during  the 
latter  months  of  pregnancy.  (^Barnes'  thex)ry  is  based  on  the  supposition 
that  the  loss  of  relation  betweeiTlTie  uterus  and  placenta  is  caused  by 
excess  of  growth  on  the  part  of  the  placenta  itself  over  that  of  the  cervix, 
which  is  not  adajited  for  its  attachment.)  The  placenta,  on  this  hy})othe- 
sis,  grows  away  from  the  site  of  its  attachment,  and  hemorrhage  results. 
It  will  be  observed  thatji^ither  this  theory  nor  that  propounded  l)y 
Jacquemier  is  readily  reconcilable  with  the  fact  that  hemorrhage  fre- 
quently does  not  begin  until  labor  has  commenced  at  term.^^  Inasnnich 
as  the  loss  of  relation  between  the  placenta  and  its  attachments,  mIucIi 
they  both  ])resuj)pose,  mjist  exist  in  every  case  of  placenta  ])rievia,  hem- 
orrhage sliould  always  occur  during  some  jxirt  of  the  last  three  months  of 
pregnancy.  {A[attjiews  I)uncan  '  has  recently  investigated  the  whole  sub- 
ject at  lengtli,  and  maintains  that  the  hcmorrlia<res  arc  ;]^'cidental.  not 
unavoidable,  being  due  to  causes  precisely  similar  to  those  which  g^ve 
rise  to  the  occasional  hemorrhages  when  the  i)lacenta  is  normally  placed* 
The  abnormal  situati(»n  of  the  placenta  of  course  renders  these  causes 
more  apt  to  operate,  but  in  th(Mr  action  he  believes  them  to  be  jn'ccisely 
similar  to  those  of  accidental  hemorrhage,  properly  so  called.  Separa- 
tion of  the  placenta  from  expansion  of  the  cervix  he  believes  to  be  the 

'  Edin.  Med.  Journ.,  vol.  1873-74,  pp.  385,  520 ;  and  Brit.  Mol.  Jnurn.,  1873,  vol.  ii. 
pp.  499,  597,  025. 


HEMORRHAGE  BEFORE  DELIVERY.  411 

cause  of  hemorrhage  after  labor  has  begun,  and  tlicn  it  may  strictly  be 
called  unavoidable,  but  hemorrhage  is  comijaratively  seldom  so  pro- 
duced during  the  continuance  of  pregnancy.  "  There  are,"  says  Duncan, 
"  four  ways  in  Avhich  this  kind  of  hemorrhage  may  occur : 

"  1.  By  the  rupture  of  a  utero-placeutal  vessel  at  or  about  the  inter-) 
nal  OS  uteri. 

"  2.  By  the  rupture  of  a  marginal  utero-placental  sinus  within  the  ) 
area  of  spontaneous  premature  detachment,  when  the  placenta  is  inserted 
not  centrally  or  covering  the  internal  os,  but  with  a  margin  at  or  near 
the  internal  os. 

"3.  By  a  partial  separation  of  the  placenta  from  accidental  causes, 
such  as  a  jerk  or  fall. 

"  4.  By  a  partial  separation  of  the  placenta,   the  consequence  of  \ 
uterine  pains  producing  a  small  amount  of  dilatation  of  the  internal  / 
os^     Such  cases  may  be  otherwise  described  as  instances  of  miscarriage 
commencing,  but  arrested  at  a  very  early  stage." 

I  see  no  reason  to  doubt  the  possibility  of  hemorrhage  being  due,  in 
many  cases,  to  the  first  three  causes,  and  in  its  production  it  would 
strictly  resemble  accidental  hemorrhage.  The  fourth  heading  refers 
the  hemorrhage  to  partial  separation  in  consequence  of  commencing 
dilatation  of  the  cervix,  but  it  explains  the  dilatation  by  the  supposi- 
tion of  commencing  miscarriage.  This  latter  hypothesis  seems  to  be 
as  needless  as  those  Avhich  presuppose  a  want  of  relation  between  the 
placenta  and  its  attachments.  We  know  that,  quite  independently  of 
commencing  miscarriage,  uterine  contractions  are  constantly  occurring 
during  the  continuance  of  pregnancy.  There  is  no  reason  to  suppose 
that  these  contractions  do  not  affect  the  cervical  as  well  as  the  fundal 
portions  of  the  uterus ;  and  in  cases  in  which  the  placenta  is  situated 
partially  or  entirely  over  the  os,  one  or  more  stronger  contractions 
than  usual  may  at  any  moment  produce  laceration  of  the  placental 
attachments  in  that  neighborhood. 

Pathological  Changes  in  the  Placenta. — A  careful  examination 
of  the  placenta  may  show  pathological  changes  at  the  site  of  separa- 
tion, such  as  have  been  described  by  Gendrin,  Simpstni,  and  other 
writers.  CjThey  probably  consist  of  thromboses  in  the  placental  cotyl- 
edons and  eflPused  blood-clots,  variously'altei-ed^ and  decplarized  accord- 
ing to  the  lapse  of  time  since  separation  took  place.^  Changes  occur  in 
the  portion  of  the  placenta  overlying  the  os  uteri,  whether  separation  has 
occurred  or  not.  (There  may  be  atrophy  of  the  placental  structure  in 
this  situation,  as  well  as  changes  of  form,  such  as  complete  or  partial 
separation  in  two  lobes,  thejunctioii  of  which  overlies  the  os  uteri.K 

The  history  of  delivery,  if  left  to  nature,  is  specially  worthy  of  J 
study,  as  guiding  to  proj^er  rules  of  treatment.  (It  sometimes  happens, 
Avlien  the  pains  are  very  strong  and  the  delivery  rajiid,  that  labor  is 
completed  without  any  hemorrhage  of  consequence.)  "  Although," 
says  Cazeaux,  "  hemorrhage  is  usually  considered  to  be  inevitable 
under  such  circumstances,  yet  it  may  not  appear  even  during  the  labor, 
and  the  dilatation  of  the  os  uteri  may  be  effected  without  the  loss  of  a 
drop  of  blood."  /Again,  Simpson  conclusively  showed  that  when  the 

'  Sinelius,  Arch.  rjen.  dc  Med.,  18(jl,  vol.  ii. 


412  LABOR. 

j)larenta  was  cxjicllod  hoforo  the  birth  of  the  cliild  all  iicuinirliatre 
cvast'd.  / 

Jiarnes'  tlieorv  of  j)]ai't'iita  j)r;evia,  which  has  been  pretty  genei-aily 
adopted,  exj)lains  satisfactorily  both  these  classes  of  cases.  Pie  describes 
the  uterine  cavity  as  divisible  into  three  zones  or  regions.  AMien  the 
placenta  is  situated  in  the  uj)per  or  middle  of  these  zones,  no  separa- 
tion or  hemorrhage  need  occur  during  labor.  AVlicn,  however,  it  is 
situated  partially  or  entirely  in  the  lower  or  cervical  zone,  the  expan- 
sion of  the  cervix  during  labor  nuist  produce  more  or  less  sejiaration, 
and  consequent  loss  of  blood.  As  soon  as  the  i)revious  ])ortion  oi"  the 
placenta  is  sufKciently  se})arated,  ])rovided  contraction  of  the  uterine 
tissue  be  present  to  seal  up  the  mouths  of  the  ve&sels,  hemon-hage  no 
longer  takes  place.  The  placenta  may  not  be  entirely  detached,  but  no 
further  hemorrhage  occurs,  in  consequence  of  the  remaining  j)orti()n 
being  engrafted  on  the  uterus  beyond  the  region  of  unsafe  attach- 
ment. 

In  the  former,  then,  of  these  classes  of  cases  the  absence  of  hcuKjr- 
rliage  is  explained  on  this  theory,  by  the  ])ains  being  sufficiently  rapid 
and  strong  to  complete  the  separation  of  the  placental  attachment  from 
the  lower  cervical  zone  before  flooding  had  taken  place ;  in  the  latter 
it  ceases,  not  necessarily  because  the  entire  placenta  is  expelled,  but 
because  of   its  detachment   from  the  area  of  dangerous  im])lantation. 

The  amount  of  cervical  exjiansion  required  for  this  purpose  varies 
in  different  cases.  Dr.  Duncan^  estimates  the  limit  of  the  sjiontaneous 
detaching  area  to  be  a  circle  of  4|  inches  diameter,  and  that  after  tlie 
cervix  has  expaiided  to  that  extent  no  further  separation  or  hemorrhage 
takes  place.  To  admit  of  the  passage  of  a  full-sized  head,  Barnes 
estimates  that  expansion  to  about  a  circle  of  6  inches  diameter  is 
necessary ;  on  the  other  hand,  he  has  sometimes  observed  "  that  the 
hemorrhage  has  completely  stopped  when  the  os  uteri  ojiened  to  the 
size  of  the  rim  of  a  wine-glass  or  even  less." 

It  will  be  seen,  then,  that  in  this  as  in  every  other  form  of  puerj>eral 
hemorrhage  the  tendency  of  uterine  contraction  is  to  check  the  hemor- 
rhage, and  that,  provided  the  j)ains  arc  sufficiently  cnci'getic,  Nature 
may  be  capable  of  stopping  the  flooding  Avithout  artificial  aid.  It  is 
but  rarely,  however,  that  she  can  be  trusted  for  the  purjiose ;  and  we 
\shall  presently  see  that  these  theoretical  views  have  an  important  ]>rac- 
tical  bearing  on  the  subject  of  treatment. 

Prognosis. — The  prognosis  to  both  the  mother  and  cliild  is  certainly 
grave  in  all  cases  of  ])laccnta  ])r{evia.  l\ead,  in  his  treatise  on  jilacenta 
])r;evia,  estimates  the  maternal  mortality,  from  the  statistics  of  a  large 
Munibcr  of  cases,  as  1  in  4 J  cases,  and  Churchill  as  1  in  3.  This  is 
unquestionably  too  higli  an  estimate,  and  based  on  statistics  tlie  accm-acy 
of  which  cannot  be  relied  on.  The  mortality  will,  of  coui"se,  greatly 
<lej)end  on  the  treatment  adojited.  Doul)tless,  if  cases  were  left  to 
nature  the  result  would  be  cpiite  as  unliivorable  as  Kead  supjioses. 
But  if  properly  managed  much  niore  successful  results  may  safely  be 
anticij^ated.  Out  of  67  cases  recorded  by  Barnes,  the  deaths  were  6, 
or  1   in   8,5.     Under  any  circumstances  the  risks  to  the  mother  are 

'  Ohd.  Trans.,  1874,  vol.  xv.  p.  189. 


HEMORRHAGE  BEFORE  DELIVERY.  413 

very  great.  Churchill  estimates  that  more  than  half  the  children  are 
lost.  (The  reasons  for  the  great  clanger  to  the  child  are  very  obvious, 
subjected  as  it  is  to  the  risk_of  asphyxia  from  the  loss  of  the  maternal 
blood,  and  from  its  res|)iratioinx!ing  carried  on  during  labor  by  a  pla- 
centa which  is  only  partially  attached ;  many  children  also  perish  from 
prematurity  or  from  malpresentation. 

Treatment. — Whenever,  in  the  latter  mouths  of  pregnancy,  a  sudden 
heiiiorrhage  occurs,  the  possibility  of  placenta  previa  will  naturally 
suggest  Itself,  and  by  a  careful  vaginal  examination,  which  under  such 
circumstances  should  always  be  insisted  od,  the  existence  of  this  com- 
plication will  generally  be  readily  ascertained.  It  is  seldom  that  the 
OS  is  not  sufficiently  dilated  to  enable  us  to  satisfy  ourselves  whether 
the  placenta  is  presenting. 

The  first  question  that  will  arise  is,  Are  we  justified  in  temporizing, 
using  means  to  check  the  hemorrhage,  and  allowing  the  pregnancy  to 
continue  ?  This  is  the  course  which  has  generally  been  recommended 
in  works  on  midwifery.  We  are  told  to  place  the  patient  on  a  hard 
mattress,  not  to  heat  or  overburden  her  with  clothes,  to  keep  her  abso- 
lutely at  rest,  to  have  the  room  cool  and  well-aired,  to  apply  cold  cloths 
to  the  vulva  and  lower  part  of  the  abdomen,  to  administer  cold  and 
acidulated  drinks  in  abundance,  and  to  prescribe  acetate  of  lead  and 
opium  or  gallic  acid  on  account  of  their  supposed  haemostatic  effect. 
Of  late  years  the  judiciousness  of  these  recommendations  has  been 
strongly  contested.  Not  long  ago  an  interesting  discussion  took  place 
at  the  Obstetrical  Society  of  London  ^  on  a  paper  in  which  Dr.  Green- 
halgh  advised  the  immediate  induction  of  labor  in  all  cases  of  placenta 
preevia.  No  less  than  six  metropolitan  teachers  of  midwifery  took  part 
in  it,  and,  although  tliey  differed  in  details,  they  (all  agreed  as  to  the 
unad visibility  of  allowing  pregnancy  to  propres"s  when  the  existence 
of  placenta  prsevia  bad  been  distinctly  ascertained . )  The  reasons  for 
this  course  are  obvious  and  unanswerable.  The  labor,  indeed,  very 
often  comes  on  of  its  own  accord,  but  should  it  not  do  so  the  patient's 
life  must  be  considered  to  be  always  in  jeopardy  until  the  case  is  ter- 
minated, for  no  one  can  be  sure  that  most  dangerous,  or  even  fatal, 
flooding  may  not  at  any  moment  come  on ;  and  the  nearer  to  term 
the  patient  is  the  greater  the  risk  to  which  she  is  subjected.  (Nor  is 
the  safety  of  the  child  likely  to  be  increased  by  delay.)  provided  it 
has  arrived  at  a  viable  age,  the  chances  of  its  being  born  alive  may 
be  said  to  be  greater  if  pregnancy  be  terminated  at  once  than  if  repeated 
floodings  occur.  (J  think,,  therefore,  that  it  may  be  safely  laid  down  a^  ( 
an  axiom  that  no  attempt  should  be  made  to  prevent  the  termination  of  ( J 
pregnancy,  but  that  our  treatment  should  rather  contemplate  its  cou-i|. 
elusion  as  soon  as  possible.)  An  exception  may,  hoAvever,  be  made  to 
this  rule  when  the  hemorrhage  occurs  for  the  first  time  before  the 
seventh  month  of  utero-gestation.  The  chances  of  the  child  surviv- 
ing would  then  be  very  small,  and  if  the  hemorrhage  be  not  alarming, 
as  at  that  early  period  is  likely  to  be  the  case,  the  measures  indicated 
above  may  be  employed  in  the  hope  of  carrying  on  the  pregnancy  until 
there  is  a  prospect  of  the  patient  being  delivered  of  a  living  child. 

1  Obstet.  Trans.,  1865,  vol.  vi.  p.  188. 


( 


414  LAiion. 

I  But  little  benefit  is  liUely  to  accrue  from  astriiif^ent  (lnif;s, !  Perfect 
rest  in  hetl  is  more  likely  to  be  beneficial  than  anytliin<r  else;  and 
astrinL!;ent  vaginal  j)es.siries  of  matico  or  perch loride  of"  in^n  might 
be  ns(.'d   with  advantage  as  local  hiemostatics. 

\\'hen  the  })eri(Kl  of  j)regnancy  or  the  urgency  of  the  case  determines 
us  to  forego  any  at tem J )t  at  temporizing,  there  are  various  plans  of  treat- 
ment to  be  considered.  These  are,  chiefly — 1.  Puncture  of  the  nwrn- 
branes ;  2.  Pliuijuif/  the  raylna ;  3.  Turning;  4.  Partial  or  com- 
plvte  fiepar<itioii  of  the  phicenta.  It  Mill  I7e  well  to  consider  in  detail 
the  relative  advantages  of,  and  indications  for,  each  of  these.  It  is 
seldom,  however,  that  "\ve  can  trust  to  any  one  per  se;  in  most  cases 
two  or  more  are  re([uired  to  be  used  in  combination. 

1.  Puncture  of  the  membranes  is  recommended  by  Barnes  as  the 
first  measure  to  ])e  adoi)ted  in  all  cases  of  placenta  pran'ia  sufficient  to 
cause  anxiety.  (^"It  is,"  he  says,  ^'{]}<^  m<^st  gpupi-nlly  oftif-nr-ions  remeflvj 
and  it  can  always  be  ajii)lied.'M  The  primary  object  gained  is  the  in- 
crease of  uterine  contraction  by  the  evacuation  of  the  liquor  anniii. 
Although  the  first  effect  of  this  may  be  to  increase  the  flow  of  blood  by 
further  separation  of  the  placenta,  the  flooding  can  generally  be  com- 
manded by  plugging  until  the  os  is  sufficiently  dilated  to  permit  the 
passage  of  the  cliild.  As  a  rule,  there  is  no  great  difficulty  in  effecting 
the  puncture,  especially  if  the  placental  ])resentation  be  only  j)artial.  A 
quill  or  other  suitable  contrivance,  guided  by  the  examining  finger,  is 
passed  through  the  cervix  and  pushed  through  the  juembranes.  In 
complete  placenta  prsevia  it  may  not  be  so  easy  to  effect  tlie  evacua- 
tion of  the  liquor  amnii,  and  although  many  authorities  advise  the 
])enetration  of  the  substance  of  the  placenta  itself,  I  am  inclined  to 
thiidv  that  it  Avould  be  better  to  abandon  the  attempt  in  such  cases 
and  trust  to  other  methods  of  treatment. 

\The  objections  Avhich  have  been  raised  to  jnuK'ture  of  the  membranes 
are  chiefly  that  it  interferes  with  the  gradual  dilatation  of  the  os  and 
renders  the  operation  of  turning  much  more  difficult.  "The  os  is  not, 
however,  so  regularly  dilated  l)v  the  bag  of  membi'anes  in  cases  of  pla- 
centa praevia  as  it  is  in  ordinary  labors.  ^Moreover,  as  the  cervical 
tissues  are  generally  relaxed  by  the  hemorrhage,  the  dilatation  is  easily 
effected.  Should  Ave  desire  to  dilate  the  os  preparatory  to  turning,  we 
can  readily  do  so  by  means  of  Barnes'  bags,  which  act  at  the  same  time 
as  an  efficient  plug.  The  objections,  therefore,  are  not  so  weighty  as 
they  might  have  been  before  these  artificial  dilators  were  used.  I J  am 
inclined,  for  these  reasons,  to  agree  with  the  recommendation  that 
])uncture  of  the  membranes  should  be  resorted  to  in  all  cases  of  jila- 
cei(ta  previa.) 

2.  Plugging  of  the  vagina — or,  still  better,  of  the  cavity  of  the 
cervix  itself — is  especially  serviceal)le  in  cases  in  which  the  os  is  not 
sufriciently  dilated  to  admit  of  turning  or  of  sejiaration  of  the  placenta, 
and  in  which  the  hemorrhage  still  continues  after  the  evacuation  of  the 
liquor  amnii.  ]3y  means  of  this  contrivance  the  escape  of  Ijlood  is 
effectually  controlled. 

The  best  way  of  ])lugging  is  to  introduce  a  spomjetent  of  sufficient 
size  into  the  cervical  canal,  and  to  keep  it  in  situ  by  a  vaginal  plug;  the 


HEMORRHAGE  BEFORE  DELIVERY.  415 

best  material  fur  the  latter,  aiitl  the  method  of"  iutroduction,  are  described 
under  the  head  of  Abortion  (p.  257).  The  sponge  tent  not  only  controls 
the  hemoi'rhage  more  effectually  than  any  other  means,  but  is  at  the 
same  time  ejecting'  dilatation  of  the  cervix.  It  cannot  be  left  in 
many  hours,  on  account  of  the  irritation  ])roduced  and  of  the  fetor 
from  accumulating^  vaginal  discharges,  and  the  consequent  risk  of 
septic  absorption.  TThis  is  by  no  means  slight,  and  it  is  now  pretty 
generally  recognized  that  the  plug  should  not  be  used  unless  other 
means  of  treatment  are  inapplicable  on  account  of  the  want  of  dila- 
tation of  the  OS.  xVs  long  as  it  is  in  position  we  should  carefully 
examine  from  time  to  time  to  see  that  no  blood  is  oozing  past  it. 
If  preferred,  a  Barnes  bag  may  be  used  for  the  same  purpose. 

While  the  plug  is  in  situ  other  modes  of  exciting  uterine  action  may 
be  very  advantageously  employed,  such  as  a  firm  abdominal  bandage, 
occasional  friction  over  the  uterus,  and  repeated  doses  of  ergot.  The 
last  is  specially  recommended  by  Dr.  Greenhalgh,  who  used  at  the  same 
time  a  plug  formed  of  an  oblong  india-rubber  ball  inflated  with  air  and 
covered  with  spongio-piline. 

On  the  removal  of  the  plug  we  may  find  that  considerable  dilatation 
has  taken  place,  perhaps  to  a  sufficient  extent  to  admit  of  labor  being 
safely  concluded  by  the  natural  efforts.  In  that  case  we  shall  find 
that,  although  the  pains  continue,  no  fresh  hemorrhage  occurs.  Should 
it  do  so,  it  will  be  necessary  to  adopt  further  measures. 

3X  Turning  has  lonp^  |ippn  considfired  the  remedy  var  excellence  in  pla- 
centa prsevia,  and  it  is  of  unquestionable  value  in  suitable  cases.  Much 
harm,  however,  has  been  done  when  it  has  been  practised  before  the  os 
was  sufficiently  dilated  to  admit  of  the  passage  of  the  hand,  or  when 
the  patient  was  so  exhausted  by  previous  hemorrhage  as  to  be  unable 
to  bear  the  shock  of  the  operation.  )  The  records  of  many  fatal  cases 
in  the  practice  of  those  who  taught,  as  did  the  large  majority  of  the 
older  writers,  that  turning  at  all  risks  was  essential,  conclusively 
prove  this  assertion. 

(  It  is  most  likely  to  prove  serviceable  when,  either  at  first  or  after 
the  use  of  the  tampon,  the  os  is  sufficiently  dilated  to  admit  the  hand, 
and  Avhen  the  streno-th  of  the  patient  is  not  much  enfeebled.  )  If  she 
have  a  small,  feeble^  and  thready  pulse  it  is  certainly  Inapplicable,  unless 
all  other  methods  of  arresting  the  hemorrhage  have  failed.  And  even 
then  it  would  be  well  to  attempt  to  rally  the  patient  from  her  exhausted 
state  by  stimulants,  etc.  before  the  operation  is  commenced. 

Provided  the  placental  presentation  be  partial,  the  operation  can  be 
performed  without  difficulty  in  the  usual  way.  In  central  implantation 
the  passage  of  the  hand  may  give  rise  to  some  difficulty.  Dr.  Rigby 
recommends  that  it  should  be  pushed  through  the  substance  of  the 
placenta  until  it  reaches  the  uterine  cavity.  It  is  hardly  possible  to 
conceive  how  this  could  be  done  Avithout  completely  detaching  the  pla- 
centa, and  still  less  to  understand  how  the  foetus  could  be  dragged 
through  the  aperture  thus  made.  (^It  Mill  be  far  better  to  pa^  the 
hand  by  the  border  of  the  placenta,  separating  it  as  we  do  soj  and 
if  we  can  ascertain  to  which  side  of  the  cervix  it  is  least  attached,  that 
should  be  chosen  for  the  purpose.     In  all  cases  in  which  it  is  possible 


41 G  LABOR. 

turning  by  tlio  bipolar  nietliod  shonkl  l»e  preferred.  In  cuscs  of"  placenta 
pran'ia  especially  it  offers  many  advantages.  The  operation  can  be  soon 
perlormed,  eoin])lete  dilatation  of  the  os  Ls  not  so  necessaiy,  and  it  in- 
volves less  brnising  of  the  cervix,  which  is  likely  to  be  specially 
dangerous.  When  once  a  lower  extremity  has  been  brought  Mithin 
the  OS  the  delivery  should  not  be  hurried.  The  lind)  of  tlie  child  forms 
a  plug  which  effectually  })revcnts  all  further  loss;  and  we  may  then  wait 
until  we  can  excite  uterine  contraction  and  terminate  the  labor  with 
safety.  Tlie  results  of  this  method  of  treating  placenta  pnevia  have 
been  excellent.  Hofmeier  relates  37  cases  managed  in  this  way  with 
only  1  death,  and  Behm  35  with  none.^  [^]  Fortunately,  the  relaxation 
of  the  uterus  which  is  so  often  present  facilitates  this  manner  of  pei-- 
forming  version,  and  it  can  generally  be  successfully  accomplished. 
Should  the  case  be  one  which  is  otherwise  suitable  for  turning,  and 
the  requisite  amount  of  dilatation  of  the  cervix  not  be  present,  the  latter 
can  generally  be  effected  in  the  s])ace  of  an  hour  or  more  (while  at  the 
same  time  a  further  loss  of  blood  is  effectually  prevented)  by  the  use  of 
Barnes'  bags. 

4.  Entire  separation  of  the  placenta  was  originally  recommended 
by  Simpson  in  his  well-known  paper  on  the  subject.  The  reasons  which 
induced  him  to  recommend  it  have  already  been  stated.  It  is  a  mistake 
to  suppose,  however,  as  is  so  often  done,  that  he  intended  to  recommend 
it  in  all  cases  alike.  This  supposition  he  was  always  careful  to  deny. 
He  advised  it  especially — 

(1)  When  the  child  is  dead. 

(2)  When  the  child  is  not  yet  viable. 

(3)  When  the  hemorrhage  is  great  and  the  os  uteri  is  not  yet  suffi- 
ciently dilated  for  safe  turning.  This  was  the  state  in  11  out  of  30 
cases  (Lee). 

(4)  When  the  pelvic  passages  are  too  small  for  safe  and  easy 
turning. 

(5)  When  the  mother  is  too  exhausted  to  bear  turning. 

(6)  When  the  evacuation  of  the  liquor  amnii  fails. 

(7)  When  the  uterus  is  too  firmly  contracted  for  turning.^ 
These  are  very  nmch  the  cases  in  which   all   modern   accoucheui'S 

would  exclude  the  operation  of  turning;  and  it  was  especially  when 
that  was  unsuitable  that  Simpson  advised  extraction  of  tlie  placenta.  As 
his  theory  of  the  source  of  hemorrhage  is  now  almost  universally  disbe- 
lieved, so  has  the  practipe  based  on  it  fallen  into  disuse,  and  it  need  not 
be  discussed  at  length.  \  It  is  very  doul^tful  whether  the  complete  sepa- 
ration and  extraction  of  the  placenta  was  a  feasible  operation;  uncpies- 
tionably,  it  can  be  by  no  means  so  easy  as  Simpson's  writings  would  lead 
us  to  supijose^  (,The  introduction  of  the  hand  far  enough  to  remove  the 
placenta  in  an  exhausted  patient  would  probably  cause  as  much  shock  as 
the  operation  of  turning  itself]  and  another  very  formidable  objection 
to  the  ])rocedure  is  the  almost  certain  death  of  the  child  if  any  time 
elapse  between  the  separation  of  the  placenta  and  the  completion  of 

^Ztschr.f.  Oeburt.  uTid  Gyndk.,  18S2,  B(\.  viii.  S.  S9,  and  1883,  Bd.  ix.  373:  "Die 
coni1)inirte  Wendiing  bei  Placenta  Prfevia." 

[■-  See  full  record  at  end  of  chapter.]  ^Selected  Obst.  Works,  p.  68. 


HEMORRHAGE  BEFORE  DELIVERY.  417 

delivery.  The  modification  of  tliis  method  so  strongly  advocated  by 
Barnes  is  certainly  mnch  easier  of  application,  and  would  appear  to 
answer  every  purpose  that  Simpson's  operation  effected.  It  is  impos- 
sible to  describe  it  better  than  in  Barnes'  own  words  :^ 

"  The  operation  is  this:  Pass  one  or  two  fingers  as  far  as  they  wull  go  I 
through  the  os  uteri,  the  hand  being  passed  into  the  vagina  if  neces-  I 
sary;  feeling  the  placenta,  insinuate  the  finger  between  it  and  the  ute-  j 
rine  wall;  sweep  the  finger  round  in  a  circle  so  as  to  separate  the  pla-  '- 
centa  as  far  as  the  finger  can  reach  ;  if  you  feel  the  edge  of  the  placenta 
where  the  membranes  begin,  tear  open  the  membranes  carefully,  espe- 
cially if  these  have  not  been  previously  ruptured  ;  ascertain  if  you  can 
W'hat  is  the  presentation  of  the  child  before  withdrawing  your  hand,  j 
Commonly,  some  amount  of  retraction  of  the  cervix  takes  place  after  ? 
the  operation,  and  often  the  hemorrhage  ceases." 

It  w^ill  be  seen  from  what  has  been  said  that  no  one  rule  of  prac- 
tice can  be  definitely  laid  down  for  all  cases  of  placenta  prsevia.  Our 
treatment  in  each  individual  case  must  be  guided  by  the  particular  con- 
ditions that  are  present ;  and  if  only  we  bear  in  mind  the  natural  his- 
tory of  the  hemorrhage,  we  may  confidently  expect  a  favorable  termi- 
nation. 

It  may  be  useful,  in  conclusion,  to -recapitulate  the  rules  which  have 
been  laid  down  for  treatment  in  the^orm  oi  a  series  of  propositions : 

I.  Before  the  child  has  reached  a  viable  age  temporize,  provided  the  1 
hemorrhage  be  not  excessive,  until  pregnancy  has  advanced  sufficiently  j 
to  afford  a  reasonable  hope  of  saving  the  child.  For  this  purpose  the  I 
chief  indication  is  absolute  rest  in  bed,  to  which  other  accessory  means  ' 
of  preventing  hemorrhage,  such  as  cold,  astringent  pessaries,  etc.,  may 
be  added. 

II.  In  hemorrhage  occurring  after  the  seventh  month  of  utero-gesta-  I 
tion  no  attempt  should  be  made  to  prolong  the  pregnancy. 

III.  In  all  cases  in  w^hicli  it  can  be  easily  effected  the  membranes  \ 
should  be  ruptured.  By  this  means  uterine  contractions  are  favored  ' 
and  the  bleeding  vessels  compressed. 

lY.  If  the  hemorrhage  be  stopped  the  case  may  be  left  to  nature.  \ 
If  flooding  continue,  and  the  os  be  not  sufficiently  dilated  to  admit  of  \ 
the  labor  being  readily  terminated  by  turning,  the  os  and  the  vagina  \ 
should  be  carefully  plugged,  while  uterine  contractions  are  promoted  by  j 
abdominal  bandages,  uterine  compression,  and  ergot.  The  plug  must  j 
not  be  left  in  beyond  a  few  hours,  and  careful  antisepsis  should  be  used.   ' 

V.  If  on  removal  of  the  plug  the  os  be  sufficiently  expanded  and 
the  general  condition  of  the  patient  be  good,  the  labor  may  be  termi- 
nated by  turning,  the  bipolar  method  being  used  if  possible,  and  the 
lower  extremity  of  the  child  will  form  a  plug  until  delivery  is  com- 
pleted. If  the  OS  be  not  open  enough,  it  may  be  advantageously 
dilated  by  a  Barnes  bag,  which  also  acts  as  a  plug. 

VI.  Instead  of,  or  before  resorting  to,  turning,  the  placenta  mav  be 
separated  around  the  site  of  its  attachment  to  the  cervix.  This  practice 
is  specially  to  be  preferred  when  the  patient  is  much  exhausted  and  in 
a  condition  unfavorable  for  bearing;  the  shock  of  turning. 

'  Obsl.  Operations,  2d  ed.  p.  417. 
27 


41 S  LABOR. 

[Dr.  J.  Braxton  Hicks'  bimanual  method  of  turning,'  as  tested 
in  Berlin  hy  Drs.  Hol'meier,  l>eliiii,  and  Lonier,  promises  iiiueli  hettei' 
results  than  any  otliei*  method  ol"  treatment  in  eases  of  phieenta  pnevia. 
Aeeording;  to  Dr.  Lonier's  report  in  the  Am.  Journ.  of  Ob.stdric^  i'or 
December,  1(S84,  Dr.  Hol'meier  operated  upon  37  cases,  and  saved  3G 
women  and  14  children;  Dr.  Behni,  upon  40  cases,  all  saved,  but  lost 
31  children  ;  and  he  himself,  with  eirjht  other  assistants,  upon  101  cases, 
savino-  94,  with  50  children.  This  *>ives  (S  deaths  of  women  and  105 
of  cliildren  in  178  cases,  or  a  mortality  of  41  ])er  cent,  of  the  former 
and  GO  ])er  cent,  of  the  latter.  Dr.  Lomer's  directions  lU'c  as  follows: 
"  Turu  by  the  bimanual  method  as  soon  as  possil)le;  pull  down  the  leg, 
and  tampon  with  it  and  with  the  breech  of  the  child  the  ruptured  vessels 
of  the  placenta.  Do  not  extract  the  chikJ  then :  let  it  come  by  itself,  or 
at  least  only  assist  its  natural  expulsion  by  jjentle  and  rare  tractions.  Do 
away  with  the  plug  as  much  as  possible;  it  is  a  dangerous  thing,  for  it 
favors  infection  and  valuable  time  is  lost  with  its  api)lication.  Do  not 
wait  iu  order  to  perform  turning  until  the  cervix  and  the  os  are  suffi- 
ciently dilated  to  allow  the  hand  to  pass.  Turn  as  soon  as  you  can  pa.ss 
one  or  two  fingers  through  the  cervix.  It  is  unnecessary  to  force  your 
finffers  throno;h  the  cervix  for  this.  Introduce  the  Avhole  hand  into  the 
vagina,  pass  one  or  two  fingers  through  the  cervix,  rupture  the  mem- 
branes, and  turn  by  Braxton  Hicks' bimanual  method."  ....  "If  the 
placenta  is  in  your  way,  try  to  rupture  the  membranes  at  its  margin  ; 
but  if  this  is  not  feasible,  do  not  lose  time:  perforate  the  placenta  with 
your  finger ;  get  hold  of  a  leg  as  soon  as  possible,  and  bring  it  down." 
—Ed.] 


^ 
«> 


CHAPTER   XIY. 

HEMORRHAGE    FROM    SEPARATION    OF    A    NORMALLY-SITUATED 

PLACENTA. 

Definition. — This  is  the  form  of  hemorrhage  which  is  generally  de- 
scribed in  obstetric  works  as  "  acciftcntal,'' m  contradistinction  to  the 
"unavoidable"  hemorrhage  of  placenta  previa.  In  discussing  the  lat- 
ter we  have  seen  that  the  term  "  accidental "  is  one  that  is  apt  to  mis- 
lead, and  that  the  cause  of  the  hemorrhage  in  placenta  pripvia  is,  in 
some  cases  at  least,  closely  allied  to  that  of  the  variety  of  hemorrhage  we 
are  now  considering. 

When,  from  any  cause,  separation  of  a  normally-situated  ])lacenta 

occurs  before  delivery,  more  or  less  blood  is  necessarily  effused  Irom  the 

ruptured  utcro-])lacental  vessels,  and  tlie  subsequent  course  of  the  case 

may  be  twofold  :(  1.  The  blood,  or  at  least  some  part  of  it,  may  find  its 

['  Lancet,  July,  1800 ;  Obdclrical  Transactions,  vol.  v.  p.  222.] 


PLATE    IV. 


-I'laccniul  site 


Bi.MMi-ciiit__yo 


Placi'iitiil  sill 


•(-    ^' 


J'listrrioi'  wall  of  iiturns 


Ketro-plafeiital  bluod-clot 


%4 —   Pliicciita  attaclu'tl 
to  wall  prodnciiif; 
■''^      its  inversion 


Anterior  wall 
of  uterus 


Membranes 


Placenta 


VERTICAL    MESIAL    SECTlOX    OK    ITEIUS    WITH    PLArEXTA    I'AKTIALLY    ATTACIIED- 
froiu  a  case  of  abdominal  section  lor  heniorrlia.ne  during  labor.     After  Barbour. 

{To  face  page  110.) 


HEMORRHAGE  BEFORE  DELIVERY.  419 

way  between  the  membranes  and  the  decidua,  and  (-\soape  from  the  9s 
utej'i.j  This  constitutes  the  typical  "accidental"  hemorrhage  of  authors. 
2.(Tne  blood  mayjjul  to  find  a  passage  externally,  and  may  collef-f.  in- 
ternally (see  Plate  IV.),  giving  rise  to  very  serious  symptoms,  and  even 
proving  fatal,  before  the  true  nature  of  the  case  is  recognized.^  Cases 
of  this  kind  are  by  no  means  so  rare  as  the  small  amount  of  attention 
paid  to  them  l)y  authors  might  lead  us  to  suppose,  and  from  the  obscur- 
ity of  the  symptoms  and  difficulty  of  diagnosis  they  merit  special  study. 
Dr.  GoodelP  has  collected  together  no  less  than  106  instances  in  which 
this  complication  occurred. 

Causes  and  Pathology. — The  causes  of  placental  separation  may 
be  very  various.  In  a  large  number  of  cases  it  has  followed  an  acci- 
dent or  exertion  (such  as  slipping  down  stairs,  stretching,  lifting  heavy 
freights,  and  the  like)  which  has  probably  had  the  effect  of  lacerating 
some  of  the  placental  attachments./  At  other  times  it  has  occurred  yjth- 
out  such  appreciable  causA  and  then  it  has  been  referred  to  some  chang^e 
in  the  uterus,  such  as  a  more  than  usually  strong  contraction  producing 
separation,  or  some  accidental  determination  of  blood  causing  a  slight 
extravasation  between  the  placenta  and  the  uterine  wall,  the  irritation 
of  which  leads  to  contraction  and  further  detachment.  Causes  such  as 
these,  which  are  of  frequent  occurrence,  will  not  produce  detachment 
except  in  women  otherwise  predisposed  to  it.  It  generally  is  met  with 
in  women  who  have  borne  many  children,  more  especially  in  those  of 
weakly  constitution  and  impaired  health,  and  rarely  in  primiparse.  Cer- 
tain constitutional  states  probably  predispose  to  it,  such  as  albuminuria 
or  exaggeraiEe3!''aiiteTHTa,  and,  still  more  so,  degenerations  and  diseases  of 
the  placenta  itself! 

This  form  of  hemorrhage  rarely  occurs  to  an  alarming  extent  until 
the  latter  months  of  pregnancy,  often  not  until  labor  has  commenced. 
The  great  size  of  the  placental  vessels  in  advanced  pregnancy  affords  a 
reasonable  explanation  of  this  fact. 

Symptoms  and  Diagnosis.-^-If,  after  separation  of  a  portion  of  the 
placenta,  the  blood  finds  its  way  between  the  membranes  and  the  de- 
cidua, its  escape  ^3<?r  vaginam,  even  although  in  small  amount,  at  once 
attracts  attention  and  reveals  the  nature  of  the  accident.)  It  is  other- 
wise when  we  have  to  do  with  a  case  of  concealed  hemorrhage,  the 
diagnosis  of  which  is  often  a  matter  of  difficulty.  Then  the  blood 
probably  at  first  collects  between  the  uterus  and  the  placenta.  Some- 
times marginal  separation  does  not  occur,  and  large  blood-clots  are 
formed  in  this  situation  and  retained  there.  More  often  the  margin  of 
the  placenta  separates,  and  the  blood  collects  between  the  membranes 
and  the  uterine  wall,  either  toward  the  cervix,  Avhere  the  presenting 
part  of  the  child  may  prevent  its  escape,  or  near  the  fundus.  In  the 
latter  case  especially  the  coagula  are  apt  to  cause  very  painful  stretching 
and  distension  of  the  uterus.  The  blood  may  also  finiL_itsJn:ay_inlo 
the  amniotic  cavity,  but  more  frequently  it  does  not  do  so,  probably,  as 
GoodelTTias' pointed  out,  because,  "  should  the  os  uteri  be  closed,  the 
membranes,  however  delicate,  cannot,  other  things  being  equal,  rupture 
any  sooner  from  the  uterine  walls,  for  the  sum  of  the  resistance  of  the 

1  Amcr.  Journ.  of  Obstd.,  1869-70,  vol.  ii.  p.  281. 


420  LABOR. 

eiick)S(.'d  li(jui)r  aimiii,  l)i'iii«i;  ((iiially  cli.<tril)iitc(l,  exactly  counti-rbalaiioes 
the  sum  of  the  pressure  exerted  by  the  elfiision."  This  point  is  f»f 
some  practical  iin])()rtanco,  because  after  rujiture  of  the  membranes  the 
li(jii»)r  ainnii  is  frecjuently  lound  untin<!;ed  with  bh»od,  and  this  mitrlit 
lead  us  to  suppox'  oiii'selves  mistaken  in  our  diaj^nosis  if  tliis  fact  were 
not  borne  in  mind. 

The  most  prujuinent  symptoms  ill  concealed  internal  heniorrliage  are 
extreme  collapse  and  exhaustion,  for  which  no  adcMpiate  cause  can  be 
assit2;ned.  These  differ  from  those  of  ordinary  syncope,  with  which  they 
mitrht  be  confounded,  chiefly  in  their  persistence  and  severity,  and  in 
the  presence  of  the  svmj)toms  attending  severe  loss  of  bhtod,  such  as  cdM- 
uess  and  i)allor  of  the  surface,  ^reat  restlessness  and  anxietv.  i-apid  ^id 
sighing  respiration,  vawnuig,  feeble,  C[Uick,  and  com))ressiblc  ])ulse. 
AMien  there  is  severe  internal  with  slight  external  hemorrhage  we  may 
be  led  to  a  proper  diagnosis  by  observing  that  the  constitutional  symp- 
toms are  nuich  more  severe  than  the  amount  of  external  hemorrhage 
would  account  for.  Uterine  pain  is  generally  present  of  a  tearing  and 
stretching  character,  sometimes  moderate  in  amount,  more  often  severe, 
and  occasionally  amounting  to  intolerable  anguish.  It  is  often  localized, 
and  doubtless  depends  on  the  distension  of  the  uterus  by  the  retained 
coagula.  If  the  distension  be  marked,  there  may  be  an  irregularity  in 
the  form  of  the  uterus  at  the  site  of  sanguineous  effusion  ;  but  this  will 
be  difficult  to  make  out,  except  in  women  with  thin  and  umisually  lax 
abdominal  parietes.  '  A  ra])id  increase  in  the  size  of  the  uterus  has  been 
described  as  a  sign  by  Cazeaux  and  others. |  It  is  not  very  likely  that 
this  will  be  appreciable  toward  the  end  of  utero-gestatiou,  as  a  very 
large  amount  of  effusion  would  be  necessary  to  produce  it.  At  an 
earlier  period  of  pregnancy,  at  or  about  the  fifth  month,  I  made  it  out 
very  distinctly  in  a  case  in  my  own  jiractice.  It  obviously  must  have 
occurred  to  an  enormous  extent  in  a  case  related  by  Chevalier,  in  wliit-h 
post-mortem  Csesarean  section  was  performed  under  the  impression  that 
the  pregnancy  had  advanced  to  term,  but  only  a  three  months'  tVetus 
was  found  imbedded  in  coagula  which  distended  the  uterus  to  the  size 
of  a  nine  months'- gestation.^  Labor-pains  may  be  entirely  absent.  If 
present  they  are  generally  feeble,  iiTcgular,  and  ineflicient. 

Differential  Diagnosis. — The  only  condition,  besides  ordinary  syn- 
cope, likely  to  be  confounded  with  this  form  of  hemorrhage  is  rupture 
of  the  uterus,  to  which  the  intense  pain  and  profound  collapse  induce 
considerable  resemblance.  TTlie  latter  rarely  occurs  until  after  labor  has 
been  some  time  in  progress  and  after  the  escape  of  the  liquor  amnii  ; 
whereas  hemorrhage  usually  occurs  either  before  labor  has  commenced 
or  at  an  early  stage^  /  The  recession  of  the  presentation  and  the  escape 
of  the  foetus  into  the  abdominal  cavity  in  cases  of  rupture  will  further 
aid  in  establishing  the  diagnosis. ) 

Prognosis. — U  he  prognosis  when  blood  escapes  externally  is,  on  the 
whole,  not  nTifivoriiblp]  The  nature  of  the  case  is  apjiarent,  and  reme- 
dial measures  are  generally  adojitcd  sufficiently  early  to  iirevent  serious 
mischief,  fit  is  diflerent  Avith  \\\o.  coi^cpjiled  form,  in  wliich  the  mortal- 
ity is  very  great. )  Out  of  GoodelFs  106  ca.ses  no  less  than  54  mothers 

'  Joum.  de  Med.  din.  etpharm.,  vol.  xxi.  p.  363. 


HEMOERJIAGE  AFTER  DELIVERY.  421 

died.  This  excessive  death-rate  is  no  doubt  ])ai'tly  due  to  the  faft  tliat 
extreme  prostration  often  occurs  before  the  existence  of  iieniorrhaj^e  is 
suspected,  and  partly  to  the  accident  generally  happening  in  women  f)f 
weakly  and  diseased  constitutions.  (The  mwnosis  to  the  child  is  still 
moi-e  p-r^ve.  Out  of  107  children,  only  o  were  born  aiive)  ilie almost 
certain  death  of  the  child  may  be  explained  by  the  fact  that  when  blood 
collects  between  the  uterus  and  the  placenta  the  fretal  portion  of  the  lat- 
ter is  ])rol)al)ly  lacerated,  and  the  child  then  also  dies  from  hemorrhage. 
Treatment. — In  this  as  in  all  other  forms  of  puerperal  hemorrhage 
the  great  haemostatic  is  uterine  contraction,  and  that  we  must  try  to 
encourage  by  all  possible  means.  The  first  thing-  to  be  done,  whether 
the  hemorrhage  be  apparent  or  concealed^  is  to  rupture  the  i-np.n;^^|7r^nps 
If  the  loss  of  blood  be  only  slight,  this  may  suffice  to  control  it,  antt  the 
case  may  then  be  left  to  nature.  A  firm  abdoniiiial  binder  should,  ho\v- 
ever,  be  applied  to  prevent  any  risk  of  blood  collecting  internally,  as 
there  is  nothing  to  prevent  its  filling  the  uterine  cavity  after  the  mem- 
branes are  ruptured,  [Contraction  may  be  further  advantageously  solici- 
ted by  uterine  compression  and  by  the  administration  of  full  closes  of 
ergotJ  If  hemorrhage  continue,  or  if  we  have  any  reason  to  suspect 
concealed  hemorrhage,  the  sooner  the  uterus  is  emptied  the  better.  If 
the  OS  be  sufficiently  dilated,  the  best  practice  will  be  tojjjnj  without 
further  delay,  using  the  bipolar  method  if  possible.  If  the  os  be  not 
open  enough,  a  Barnes  bag  should  be  introduced,  while  firm  pressure  is 
kept  up  to  prevent  uterine  accumulation.  Should  the  collapsed  condition 
of  the  patient  be  very  marked,  the  mere  shock  of  the  operation  might 
turn  the  scale -against  her.  Under  such  circumstances  it  may  be  better 
j^ractice  to  delay  further  procedure  until,  by  the  administration  of  stim- 
ulants, warmth,  etc.,  we  have  succeeded  in  producing  some  amount  of 
reaction,  keeping  up,  in  the  mean  while,  firm  pressure  on  the  uterus. 
Should  the  head  be  low  down  in  the  pelvis,  it  may  be  easier  to  complete 
labor  by  means  of  the  forceps. 


CHAPTER  Xy. 

HEMORRHAGE    AFTER    DELIVERY. 

Its  Importance. — Hemorrhage  during-  or  shortly  after  the  third 
stage  of  labor  is  one  of  the  most  trying  and  dangerous  accidents  con- 
nected with  parturition.  Its  suddeu  and  unexpected  occurrence  just 
after  the  labor  aj^pears  to  be  haj>j)ily  terminated,  and  its  alarming  effect 
on  the  patient,  who  is  often  placed  in  the  utmost  danger  in  a  few  mo- 
ments, tax  the  presence  of  mind  and  the  resources  of  the  practitioner 


422  LABOR. 

to  tlie  utmost,  and  render  it  an  iinixTative  duty  on  every  one  who 
practises  niidwilery  to  make  liimsell'  thoroughly  acquainted  with  its 
causes  and  preventive  and  curative  treatment.  There  is  no  emergency 
in  obstetrics  wliich  leaves  less  time  for  reflection  and  consultation,  and 
tiie  life  of  the  patient  will  often  de])end  on  the  prompt  and  immediate 
action  of  the  medical  attendant. 

Frequency  of  Post-partum  Hemorrhage. — Post-partura  hemor- 
rhage is  one  of  the  most  frequent  complications  of  delivery.  I  do  not 
know  of  any  statistics  which  enable  us  to  judge  with  accuracy  of  its  fre- 
quency, but  I  believe  it  to  be  an  unquestionable  fact  that,  especially  in 
the  upjKM- ranks  of  society,  it  is  very  common  indeed.  This  is  jn-obably 
due  to  the  ellects  of  civilization  and  to  the  mode  of  life  of  ])atients  of 
that  class,  mIiosc  whole  surroundings  tend  to  produce  a  lax  habit  of 
body  "svhich  favors  uterine  inertia,  tlie  princij^al  cause  of  post-partum 
hemorrhage.  In  the  report  of  the  Registrar-General  for  the  five  years 
from  1872  to  1876,  3524  deaths  are  attributed  to  flooding.  'Tlie 
majority  of  these  must  have  been  caused  by  post-partum  hemorrhage, 
although  some  may  have  been  from  other  forms. 

F(jrtunately,  it  is,  to  a  great  extent,  a  i)reventable  accident.  I 
believe  this  fact  cannot  be  too  strongly  impressed  on  the  practitioner. 
l(^  If  the  third  stage  of  labor  be  properly  conducted,  if  every  case  be 
treated,  as  every  case  ought  to  be,  as  if  hemorrhage  were  impending, 
it  would  be  much  more  infrequent  than  it  is.  )/  It  is  a  curious  fact  that 
post-partum  hemorrhage  is  much  more  common  in  the  practice  of  f-ome 
medical  men  than  in  that  of  others,  the  reason  being  that  those  who 
meet  with  it  often  are  careless  in  the  management  of  their  patients 
immediately  after  the  birth  of  the  child.  That  is  just  the  time  when 
the  assistance  of  a  properly  qualified  practitioner  is  of  value,  much  more 
so  than  before  the  second  stage  of  labor  is  concluded ;  hence  \\hen  I  hear 
that  a  medical  man  is  constantly  meeting  with  severe  post-jiartum  hem- 
orrhage I  hold  myself  justified,  ipso  fado,  in  inferring  that  he  does  not 
know^  or  does  not  practise  the  proper  mode  of  managing  the  third  stage 
of  labor. 

Causes. — The  placenta,  as  we  have  seen,  is  separated  by  the  last 
pains,  and  the  blood,  which  in  greater  or  less  quantity  accompanies  the 
foetus,  probably  comes  from  the  utero-placental  vessels  which  are  then 
lacerated.  Almost  immediately  afterward  the  uterus  contracts  firndy, 
and  in  a  typical  labor  assumes  the  hai'd  cricket-ball  form  which  is  so 
comforting  to  the  accouclieur  to  feel.  (See  Plate  V.)  Tlie  result  is  the 
compression  of  all  tlie  vascular  trunks  which  ramify  in  its  walls,  both 
arteries  and  veins,  and  thus  the  flow  of  blood  through  them  is  pre- 
vented. By  referring  to  Avhat  has  been  said  as  to  the  anatomy  of  the 
mascular  fibres  of  the  gravid  uterus,  especially  at  the  placental  site 
(p.  62),  it  W'ill  be  seen  how  admirably  they  are  adapted  for  this  pur- 
pose. The  arrangement  of  the  vessels  themselves  favors  the  luemo- 
static  action  of  uterine  contraction.  The  large  venous  sinuses  are  placed 
in  layers  one  aliove  the  other  in  the  thickness  of  the  uterine  walls,  and 
they  anastomose  freely.  AVhen  the  superimposed  layers  comnuniicate 
with  those  immediately  below  them,  the  junction  is  by  a  falciform  or 
semilunar  opening  in  the  floor  of  the  vessel  nearest  the  extei'ual  surface 


JIEMURIUIAGE  AFTER  DELIVERY.  423 

of  the  uterus.  Within  the  iuaro;ins  of  this  aperture  there  are  muscular 
fil)res,  the  contraction  of  wliich  prol)ably  tends  to  i)reveut  retrogression 
of  blood  from  one  layer  of  vessels  into  the  other.  The  venous  sinuses 
themselves  are  of  a  flattened  form,  and  they  are  intimately  attached  to 
the  muscular  tissues.  It  is  obvious,  theu,  that  these  anatomical  arrange- 
ments are  eminently  adapted  to  facilitate  the  closure  of  the  vessels. 
They  are,  however,  large,  and  are  destitute  of  valves  j(  £^d  if  contrac- 
tionlx'  absent  or  if  it  be  partial  and  h-regular,  it  is  equally  easy  to 
unckislaiul  why  blood  should  pour  forth  ui  the  appalling  amount 
which  is  sometimes  observed.) 

If  uterine  action  be  firm,  regular,  and  continuous,  the  vessels  must 
be  sealed  up  and  hemorrhage  effectually  prevented.  This  fact  has 
been  doubted  by  many  authorities.  Gooch  was  the  first  to  describe 
what  he  called  "a  peculiar  form  of  hemorrhage"  accompanying  a 
contracted  womb.  Similar  observations  have  been  made  by  other 
writers,  such  as  Yelpeau,  Rigby,  and  Gendrin.  Simpson  says  on  this 
point  that  strong  uterine  contractions  "are  not  probably  so  essential 
a  part  in  the  mechanism  of  the  prevention  of  hemorrhage  from  the 
open  orifices  of  the  uterine  veins  as  we  might  a  priori  suppose."  ^  With 
regard  to  Gooch's  cases,  it  has  been  pointed  out  that  his  own  descrip- 
tion proves  that,  however  firmly  the  uterus  may  have  contracted  imme- 
diately after  the  expulsion  of  the  child,  it  must  have  subsequently 
relaxed,  for  he  passed  his  hand  into  it  to  remove  retained  clots — a 
raanceuvre  which  he  could  not  have  practised  had  tonic  contraction 
been  present.  In  some  of  these  cases  the  hemorrhage  has  been  found 
to  come  from  a  laceration  of  the  cervix.  Of  course  blood  may  readily 
escape  from  mechanical  injury  of  this~kind,  although  the  uterus  itself 
be  in  a  satisfactory  state  of  contraction ;  and  the  possibility  of  this 
occurrence  should  always  be  borne  in  mind.  Instances  of  the  success- 
ful treatment  of  this  variety  of  post-partum  hemorrhage  by  sutures 
applied  to  the  lacerated  cervix  have  been  related  by  Fallen  and 
others. 

/Although,  then,  we  may  admit  that  post-partum  hemorrhage  is*' 
incompatible  with  persistent  contraction  of  the  uterus,  it  by  no  means 
follows  that  the  converse  is  true./  On  the  contrary,  it  is  not  uncommon; 
to  meet  with  cases  in  which  the  uterus  is  large,  and  apparently  quite 
flaccid,  and  in  which  there  is  no  loss  of  blood//  Alternate  relaxation 
and  contraction  of  the  uterus  after  delivery  are  also  of  constant  occur- 
rence, and  yet  hemorrhage  during  the  relaxation  does  not  take  place. 
The  explanation  no  doubt  is  that  immediately  after  the  birth  of  the 
child  there  was  sufficient  contraction  to  prevent  hemorrhage,  and  that 
during  its  continuance  coagula  formed  in  the  mouths  of  the  uterine 
sinuses  by  which  they  were  sufficiently  occluded  to  prevent  any  loss 
when  subsequent  relaxation  occurred,  i 

In   all   probability,  both  uterine  contraction  and  thrombosis  are  in 
operation   in  ordinary  cases;  and   we  sliall   presently  see  that  all  the 
means  employed  in  the  treatment  of  post-partum  hemorrhage  act  by 
pj^-oducing  one  or  other  of  them. 
'   Uterm£_iiiertia  after  labor,  then,  may  be  regarded  as  the  one  great 

1  Selected  Obstd.  Works,  p.  234. 


424  LABOn. 

})riinarv  oauso  of  post-partnm  lu-niorrlinfrc  X  but  there  are  various 
sL'coiulary  causes  wliidi  tend  to  produce  it,  oiie  of  tlie  most  freijueiit 
of  whic-li  is  exliaustion  followiiii!;  a  protracted  labor.  \  The  uterus  j^cts 
uorn  out  by  its  cllbrts,  ami  when  the  fcetus  is  expelk'd  it  remains  in  a 
relaxed  state  and  hemorrhage  results.'  Over-distension  of  the  uterus 
acts  in  the  same  way.  Henee  hemorrhage  is  very  frequently  met  with 
when  there  has  been  an  excessive  amount  of  liquor  amnii  or  in  nudti- 
plc  pregnancies.  One  of  the  worst  cases  I  ever  met  with  was  after  the 
l)irth  of  tri])lets,  the  uterus  having  been  of  an  enormous  size.  Kapid 
emotvinor  of  the  uterus,  during  wliicli  there  has  Jiot  been  sufficient  tune 
for  complete  separation  of  the  placenta,  often  tends  to  the  same  result. 
This  is  the  reason  why  hemorrhage  so  frequently  follows  forceps  delivery, 
especially  if  the  operation  have  been  unduly  hurried  ;  and  it  is  ojie  of 
the  chief  dangers  in  what  are  termed  "precipitate  labors."  The  t^'-eu- 
eral  condition  of  the  patient  may  also  strongly  predispose  to  it.  Thus, 
i^^nore^bften  met  with  m  women  who  have  borne  families,  especially 
if  they  be  weakly  in  constitution,  comparatively  seldom  in  primi})ane, 
and  for  the  same  reason  that  after-paius  are  most  conuuon  in  the  former 
— namely,  that  the  uterus,  Aveakened  by  frequent  childbearing,  contracts 
inefficiently.  The  experience  of  practitioners  in  the  tropics  shows  that 
European  women,  debilitated  by  the  relaxing  effects  of  warm  climates, 
are  peculiarly  prone  to  it,  and  it  forms  one  of  the  chief  dangers  of  child- 
birth amongst  the  English  ladies  in  India. 

f  Another  important  cause  of  post-partuni  hemorrhage  is  partial  and 
ijj'Pprnlar  nnnfrap^.jon  of  the  utcrus.  \  Part  of  the  muscular  tissue  is 
firmly  contracted,  while  another  pari  is  relaxed,  and  the  latter  very 
often  the  placental  site.  This  has  been  especially  dwelt  on  by  Simp- 
son. He  says  :  "  The  morbid  condition  which  is  most  frequently  and 
earliest  seen  in  connection  with  post-partum  hemorrhage  is  a  state  of 
irregularity,  and  w-ant  of  equability  in  the  contractile  action  of  differ- 
ent parts  of  the  uterus — and,  it  may  be,  in  different  planes  of  the  nnis- 
cular  fibres — as  marked  by  one  or  more  points  in  the  organ  feeling  hard 
and  contracted  at  the  same  time  that  other  })ortions  of  the  parietes  are 
soft  and  relaxed." 

\Oue  peculiar  variety,  which  has  been  much  dwelt  on  by  writers,  and 
is  a  prominent  bugbear  to  obstetricians,  is  the  so-called  "hour-glass  con- 
tracfion."/\  This,  in  reality,  seems  to  depend  on  spasmodic  contraction 
of  the  intertill  '^>s  ulori  by  means  of  which  the  placenta  becomes 
enc\'?itT?d  in  the  lip])er  pol-tion  of  the  ii Ferns,  which  is  relaxed.  On 
introducing  tlie  hand  it  first  passes  through  the  lax  cervical  canal,  luitil 
it  comes  to  the  closed  internal  os,  with  the  umbilical  cord  passing  through 
it,  Avhich  has  generally  been  supposed  to  be  a  circular  contraction  of  a 
portion  of  the  body  of  the  uterus. 

Encystment  of  the  jdaccnta,  however,  although  more  rarely,  unques- 
tionably takes  ])lace  in  a  ])ortion  only  of  the  body  of  the  uterus  (Fig. 
149).  Then,  a])parently,  the  jrlacental  site  remains  more  or  less  ]x\va- 
lyzed,  with  the  placenta  still  attached,  while  the  remainder  of  the  body 
of  the  uterus  contracts  firmly,  and  thus  encystment  is  produced. 

These  irregular  contractions  of  the  uterus  are  by  no  means  so  common 
as  our  older  authors  supi)osed.     AVheu  they  do  occur,  I  believe  them 


HEMORRHAGE  AFTER  DELIVERY. 


425 


almost  invariably  to  tlcpend  on  defective  nuiuagenient  of  the  third 
stage  of  labor.  "  Tlie  in(jst  frequent  cause,"  says  Kigby/  "  is  from 
over-anxiety  to  remove  the  placenta  ;  the  cord  is  frequently  pulled  at, 
and  at  length  the  os  uteri  is  excited  to  contract."  AVhile  this  is  being 
done  no  attempts  are  probably  being  made  to  excite  the  fundus  to 

Fig.  149. 


Regular  Contraction  of  the  Uterus,  witli  Encystment  of  the  Placenta. 

proper  action,  and  therefore  the  hour-glass  contraction  is  established. 
Oohnstoue^  has  pointed  out  that  in  a  large  proportion  of  cases  ergot 
nas  been  given  before  the  expulsion  of  the  placenta.  Duncan  say S  of 
this  condition :/ "  Hour-glass  contraction  cannot  exist  unless  the  parts 
above  the  contraction  are  in  a  state  of  inertia ;  were  the  higher  parts 
of  the  uterus  even  in  moderate  action,  the  hour-glass  contraction  Avould 
soon  be  overcome."  ^  If  placental  expression  were  always  employed, 
if  it  were  the  rule  to  eifect  the  expulsion  of  the  placenta  by  a  vis  it 
tergo  instead  of  extracting  by  a  vis  a  fronte,  I  feel  confident  that  these 
irregular  and  spasmodic  contractions — of  the  influence  of  which  in  pro- 
ducing hemorrhage  there  can  be  no  question — would  rarely  if  ever  be 
met  with.  It  is  to  be  observed  that  even  in  these  cases  it  is  not  because 
the  uterus  is  in  a  state  of  partial  contraction,  but  because  it  is  in  a  state 
of  ])artial  relaxation,  that  hemorrhage  ensues. 

Placental  Adhesions.— ^Adhesions  of  the  placenta  to  the  uterine 
parietes  may  cause  hemorrhage,  (■s])ccially  li  tliey  be  partial  ana  the 
remainder  of  the  placenta  be  detached)  The  frequency  of  these  has 
been  over-estimated.  Many  cases  believed  to  be  examples  of  adherent 
placentre  are,  in  reality,  only  cases  of  placentre  retained  from  uterine 
inertia.  The  experience  of  all  who  see  much  midwifery  will  probably 
corroborate  the  observation  of  Braun,  that "  abnormal  adhesions  and  hour- 
glass contraction  are  more  frequently  encountered  in  tiie  experience  of 
the  young  practitioner,  and  they  diminish  in  frequency  in  direct  ratio  to 
increasing  years."*  /The  cause  of  adhesions  is  often  obscure,  but  it  most 
probably  results  from  a  morbid  state  of  the  deeidua,  which  is  produced 


'  Rigby's  Midwiferii,  p.  225. 
^  Researches  in  Obstetrics,  p.  3S9. 


^  Glasgow  Med.  Journ.,  18S7,  vol.  xxvii.  p.  188. 
*  Braun's  Lectures,  18G9. 


42(j  LAliOPx. 

bv  aiitececk'nt  disease  of  the  uterine  mucous  meuibranc;  then  tiie 
adiu'sit)!!  is  apt  to  recur  in  subsequent  prejiuanciesA  The  deciclua  is 
altered  and  tliickened,  and  patches  ot"  calcareous  and  fibrous  degenera- 
tion may  be  often  found  on  the  attached  surface  of  the  placenta.  Most 
frequently  the  placenta  is  oidy  partially  adherent,  patches  of  it  remain 
firndy  attached  to  the  uterus,  while  the  rest  is  separated;  lience  the 
uterine  walls  remain  relaxed  and  hemorrhage  fre(piently  follows.  The 
tliagnosis  and  manaticment  of  these  very  troublesome  cases  will  be  found 
described  under  the  head  of  treatment  (p.  429j. 

Finally,  I  think  it  must  be  admitted  that  there  are  some  women  who 
really  merit  the  appellation  of  ^^fiooders"  which  has  been  aj)j)lied  to 
them,  and  who,  do  Nvhat  we  may,  have  the  most  extraordinary  tendency 
to  hemorrhage  after  delivery.  1  do  not  think  that  these  cases,  liowever, 
are  by  any  means  so  common  as  some  have  sui)posed.  1  have  attended 
several  j)atients  who  have  nearly  lost  their  lives  from  post-partum  hem- 
orrhage in  ibrmer  labors,  some  who  have  suffered  from  it  in  every  pre- 
ceding confinement,  and  I  have  only  met  with  two  cases  in  which  the 
assiduous  use  of  preventive  treatment  failed  to  avert  it.  In  these  (one 
of  which  I  have  elsewhere  published  in  detaiP),  in  s])ite  of  all  my 
efforts,  I  could  not  succeed  in  keeping  up  uterine  contraction,  and  the 
patients  would  certainly  have  lost  their  lives  were  it  not  for  the  means 
Avhich  modern  improvements  have  fortunately  placed  at  our  disposal 
for  producing  thrombosis  in  the  mouths  of  the  bleeding  vessels.  The 
nature  of  these  rare  cases  recjuires  further  investigation :  possibly  they 
may,  to  some  extent,  be  the  subjects  of  the  so-called  hemorrhagic 
diathesis. 

/  The  loss  of  blood  may  commence  immediately  after  the  birth  of 
trie  child  before  the  expulsion  of  the  placenta,  or  not  until  some  time 
afterward,  when  the  contracted  uterus  has  again  relaxedJ  It  may  ct»m- 
mence  gradually  or  suddenly :  in  the  latter  case  it  may  begin  with  a 
gush,  and  ni  tlie  worst  form  the  bedclothes,  the  bed,  and  even  the  floor, 
are  deluged  with  the  blood  which,  it  is  no  exaggeration  to  say,  is  jiour- 
ing  from  the  patient.  If  now  the  hand  be  placed  on  the  abdomen,  we 
shall  miss  the  hard  round  ball  of  the  contracted  uterus,  which  will  be 
found  soft  and  flabby,  or  we  may  even  be  unable  to  make  out  its  contour 
at  all.  If  the  hemorrhage  be  slight  or  if  we  succeed  in  controlling  it  at 
once,  no  serious  consequences  follow;  but  if  it  be  excessive  or  if  we  fail 
to  check  it,  the  gravest  results  ensue. 

There  are  few  sights  more  appalling  to  witness  than  one  of  the  worst 
cases  of  post-partum  hemorrhage.  The  pulse  becomes  rapidly  affected, 
and  may  be  reduced  to  a  mere  thread  or  it  may  become  entirely  imper- 
ceptible. Syncope  often  comes  on — not  in  itself  always  an  unfavorable 
occurrence,  as  it  tends  to  promote  thrombosis  in  the  venous  sinuses;  or, 
short  of  actual  syncoj)e,  there  may  be  a  feeling  of  intense  debility  and 
faintncss.  Extreme  restlessness  soon  supervenes,  the  j)atient  throws  her- 
self about  the  bed,  tossing  her  arms  wildly  above  her  head;  respiration 
becomes  gasping  and  sighing,  the  "besoin  de  respirer"  is  acutely  felt, 
and  the  patient  cries  out  for  more  air;  the  skin  becomes  deadly  cold  and 
covered  with  profuse  persj^iratiou :  if  the  hemorrhage  continue  unchecked, 

'  Obst.  Journ.,  1873-74,  vol.  i.  p.  89. 


HEMORRHAGE  AFTER  DELIVERY.  427 

we  next  may  have  complete  loss  of  vision,  jaftitation,  convulsions,  and 
death. 

Formidable  as  such  symptoms  are,  it  is  satisfactory  to  know  that 
recovery  often  takes  place,  even  when  the  powers  of  life  seem  reduced 
to  the  lowest  ebb.  If  we  can  check  the  hemorrhage  while  there  is  still 
some  power  of  reaction  left,  however  slight,  we  may  not  unreasonably 
hope  for  eventual  recovery.  The  constitution,  however,  may  have 
received  a  severe  shock,  and  it  may  be  months,  or  even  years,  before 
the  patient  recovers  from  the  effects  of  only  a  few  minutes'  hemor- 
rhage. A  death-like  pallor  frequently  follows  these  excessive  losses, 
and  the  patient  often  remains  blanched  and  exsanguine  for  a  long  time. 

Treatment. — The  preyj^ntive  treatment  of  post-partuni  hemor- 
rhage should  be  carefully  practised  in  every  case  of  labor,  however 
normal.  If  the  practitioner  make  a  habit  of  never  removing  his  hand 
from  the  uterus  after  tlie  birth  of  the  child  until  the  placenta  is  cxpellecA 
and  of  keeping  up  continuous  uterine  contraction  for  at  least  half  aj 
hour  after  delivery  is  completed,  not  necessarily  by  I'ncfiou  on  ttie 
tu'ndus,  but  by  simply  grasping  the  contracted  womb  with  the  palm  of 
the  hand  and  preventing  its  undue  relaxation,  cases  of  post-partum 
flooding  will  seldom  be  met  with.  As  a  rule,  we  should,  I  think,  not 
apply  the  binder  until  at  least  that  time  has  elapsed.  The  binder  is  an 
effective  means  of  keeping  up,  but  not  of  producing,  contraction,  and  it 
should  never  be  trusted  to  for  the  latter  purpose.  If  it  be  ])ut  on  too 
soon,  the  uterus  may  relax  under  it,  and  become  filled  with  clots  with- 
out the  practitioner  knowing  anything  about  it ;  whereas  this  cannot 
possibly  take  place  as  long  as  the  uterine  globe  is  held  in  the  hollow  of 
the  hand.  I  have  seen  more  than  one  serious  case  of  concealed  hemor- 
rhage result  from  the  too  common  habit  of  putting  on  the  binder  imme- 
diately after  the  removal  of  the  placenta.  ( I  believe  also,  as  I  have 
formerly  said,  that  it  is  thoroughly  good  practice  to  administer  a  full 
dose  of  the  Ijaijid  extract  of  ergot  in  all  cases  after  the  placenta  has  been 
expelled,  to  ensure  persistent  contraction  and  to  lessen  the  chance  of 
blood-clots  being  retained  in  utero.\ 

These  are  the  precautions  which  fdiould  be  used  in  all  cases  alike ; 
but  wlien_we  have  reason  to  fear  the  occurrence  of  hemorrhage  from 
the  history  of  previous  lal^ors  "or  other  cause,  special  care  should  be 
taken.  ^The  ergot  should  be  given,  and  preferably  in  the  form  of  the 
subcutaneous  injection  of  crgotine,  before  the  birth  of  the  child,  when 
the  presentation  is  so  far  advaiiced  that  we  estimate  that  labor  will  be 
concluded  in  from  ten  to  twenty  minutes,  as  we  can  hardlv  expect  the 
drug  to  produce  any  effect  in  less  time.  .^  Particular  attention,  moreover, 
should  then  be  paid  to  the  state  of  the  uterus.  Every  means  should  be 
taken  to  ensure  regular  and  strong  contraction,  and  it  is  advisable  to 
rupture  the  meml)ranes  early,  as  soon  as  the  os  is  dilated  or  dilata- 
ble, to  ensure  stronger  uterine  action.  If  any  tendency  to  relaxation 
occur  after  delivery,  a  piece  of  ice  should  be  passed  into  the  vagina 
or  into  the  uterus.  Should  coagula  collect  in  the  uterus,  they  mav  be 
readily  expelled  by  firm  pressure  on  the  fundus,  and  the  finger  should 
be  passed  occasionally  up  to  the  cervix,  and  any  Avhich  are  felt  there 
should  be  gently  picked  away. 


428  LABOR. 

\\'c  slidiild  be  sjK'cially  on  our  <;ii;inl  in  all  cases  in  which  the  pulse 
docs  not  iall  alter  deliveiT.  It'  it  heat  at  100  or  more  .some  ten  minutes 
or  a  quarter  oi"  an  hour  after  the  birth  ol"  the  child,  hemorrlia<i'e  not  un- 
frequently  t'ollows;  and  hence  it  is  a  good  practical  rule,  which  may  save 
much  trouble,  that  a  patient  should  uever  be  left  unless  the  pulse  has 
fallen  to  its  natural  standard. 

As  there  are  only  two  means  which  nature  adopts  in  the  prevention 
of  i)()st-partum  liemoi-rha^e,  so  the  remedial  measures  alstj  may  be 
divided  into  two  classes:  fl.  Those  which  act  by  the  j)roduetion  of 
uterine  contraction) (^2.  Those  which  act  by  producing  thrombosis  iu 
the  vessels^  Of  these  the  first  are  the  most  commonly  used ;  and'it  is 
only  iu  the  worst  cases,  in  which  they  have  been  aasiduously  tried 
and  liave  failed,  that  we  resort  to  those  coming  under  the  second 
heading. 

The  patient  should  be  placed  on  her  l)ac'k,  in  which  position  we  can 
more  readily  command  the  uterus  as  well  as  attend  to  her  general  state. 
If  the  uterus  be  found  relaxed  and  full  of  clots,  by  firmly  grasj)ing  it 
in  the  hand  contraction  may  be  evoked,  its  contents  expelled,  and  fur- 
ther hemorrhage  at  once  arrested.  '  Should  this  fortunately  be  the  case, 
we  nuist  keep  up  contraction  by  gently  kneading  the  uterus  until  we 
are  satisfied  that  undue  relaxation  will  not  recur. 

The  powerful  influence  of  friction  iu  promoting  contraction  cannot 
be  doubted,  and  nothing  will  replace  it ;  no  doubt  it  is  fatiguing,  but  as 
long  as  it  is  effectual  it  must  be  kept  up.  Xo  roughness  should  be  used, 
as  we  might  produce  subsequent  iujury,  but  it  is  quite  possible  to  use 
considerable  pressure  without  any  violence. 

Another  method  of  applying  uterine  pressure  has  been  strongly  advo- 
cated by  Dr.  Hamilton  of  Falkirk,  and  it  may  be  serviceable  where 
there  is  a  constant  draining  from  the  uterus  aud  a  capacious  pelvis.  (  It 
consists  in  passing  the  fingers  of  the  right  hand  high  up  into  the  pos- 
terior cul-de-sac  of  the  vagina,  so  as  to  reach  the  jiosterior  surface  of 
the  uterus,  while  counter-pressure  is  exercised  by  the  left  hand  through 
the  abdomen.  The  anterior  and  posterior  walls  of  the  uterus  are  thus 
closely  pressed  together.) 

During  the  time  that  pressure  is  being  applied  attention  can  be  paid 
to  general  treatment ;  and  in  giving  his  directions  to  the  bystanders  the 
practitioner  should  be  calm  and  collected,  avoiding  all  hurry  and 
excitement.  !  A  full  dose  of  ergot  should  l)e  administered,  and  if  one 
have  already  been  given,  it  should  be  repeated.  AVe  cannot,  however, 
look  upon  ergot  as  anything  but  a  useful  accessory,  and  it  is  one  which 
requires  considerable  time  to  operate.  The  hypodermic  use  of  ergotinc 
offers  the  double  advantage,  in  severe  cases,  of  acting  with  greater 
]K)wer  and  much  more  rapidly  than  the  usual  method  of  administra- 
tion. It  should,  therefore,  always  be  used  in  preference.  An  aqueous 
solution  of  ergotinine,  irgu  ^^  '^  grain  in  10  minims,  has  been  highly 
recommended  by  Chahl)azain  of  Paris  as  acting  more  energetically,  and, 
it  has  seemed  to  me,'  has  had  a  good  effect. 

The  sudden  flow  will  probably  have  produced  exhaustion  and  a  tend- 
ency to  syncope,  and  the  administration  of  stimulants  will  be  necessary. 

'  Obst.  Trans,  for  1882,  vol.  xxiv.  p.  286. 


HEMORRHAGE  AFTER  DELIVERY.  429 

The  amount  must  be  regulated  by  the  state  of  the  pulse  and  the  dogvee 
of  exhaustion.  There  is  no  more  absurd  mistake,  howevei",  than  im- 
plicitly relying  on  tlu;  brandy-bottle  to  cheek  post-partiun  liemorrhage. 
In  the  worst  cases  absorption  is  in  abeyance,  and  brandy  may  be  poured 
down  in  abundance,  the  practitioner  believing  that  he  is  rousing  his 
jxitient,  "while  he  is,  in  fact,  only  filling  the  stomach  with  a  rpiantity  of 
fluid  which  is  eventually  thrown  up  unaltered.  I  have  more  than  once 
seen  symptoms  produced  by  the  over-free  use  of  brandy  in  slight  flood- 
ings  which  were  certainly  not  those  of  hemorrhage.  I  remember  on 
one  occasion  being  summoned  by  a  practitioner,  with  a  view  to  transfu- 
sion, to  a  patient  who  was  said  to  be  insensible  and  collapsed  from  hem- 
orrhage. I  found  her,  indeed,  unconscious,  but  with  a  flushed  face,  a 
bounding  pulse,  a  firmly  contracted  uterus,  and  deep  stertorous  breath- 
ing. On  inquiry  I  ascertained  that  she  had  taken  an  enormous  quan- 
tity of  brandy,  which  had  brought  on  the  coma  of  profound  intoxica- 
tion, while  the  hemorrhage  had  obviously  never  been  excessive.  ^ 

M?he  hypodermic  injection  of  sulphuric  ether  is  a  remedy  of  great    I  / 
value  as  a  powerful  stimulant  in  cases  \n  which  exhaustion  is  very     /^ 
great.     It  has  the  advantage  of  acting  rapidly,  and  of  being  capable  of 
administration  when  the  patient  is  unable  to  swallow.     A  fluiddrachm 
may  be  injected  into  the  nates  or  thigh,  and  the  injection  may  be  re- 
peated as  the  state  of  the  patient  may  require. 

The  window  should  be  thrown  widely  open  to  allow  a  current  of 
fresh  cold  air  to  circulate  freely  through  the  room.  The  pillows  should 
be  removed,  the  head  kept  low,  and  the  patient  should  be  assiduously 
fanned. 

If  bleeding  continue  or  if  it  commence  before  the  placenta  is 
expelled,  the  hand  should  be  carefully  and  gently  passed  into  the  uterus 
and  its  cavity  cleared  of  its  contents.  The  mere  presence  of  the  hand 
within  the  uterus  is  a  powerful  inciter  of  uterine  action.  When  the 
placenta  is  retained  it  is  the  more  essential,  as  the  hemorrhage  cannot 
possibly  be  checked  as  long  as  the  uterus  is  distended  by  it.  During 
the  operation  the  uterus  should  be  supported  by  the  left  hand  exter- 
nally, and  by  using  the  two  hands  in  concert  the  chances  of  injuring 
the  textures  are  greatly  lessened. 

Treatment  of  Hour-glass  Contraction. — If  the  so-called  "  hour- 
glass contraction  "  be  present  or  if  the  placenta  be  morbidly  adherent, 
'the  operation  will  be  more  difficult  and  will  require  much  judgment 
and  care.  (The  spasmodic  contraction  of  the  inner  os  in  the  former 
case  may  generally  be  overcome  by  gentle  and  continuous  pressure  of 
the  fingers  passed  within  the  contraction,  while  the  uterus  is  supported 
from  without.  \  By  this  means,  too,  further  hemorrhage  can  in  most 
cases  be  controlled  until  the  spasm  is  sufficiently  relaxed  to  admit  of 
the  passage  of  the  hand. 

Signs  of  Adherent  Placenta. — There  are  no  very  reliable  signs  to 
indicate  morbid  adhesion  of  the  placenta  previous  to  the  introduction 
of  the  hand.  The  following  are  the  symptoms  as  laid  down  by  Barnes, 
any  of  which  might,  however,  accomjiany  non-detachment  of  the  pla- 
centa unaccompanied  by  adhesion  :  "  You  may  suspect  morbid  adhesion 
if  there  have  been  unusual  difficulty  in  removing  the  placenta  in  pre- 


430  LABOR. 

viuiisi  labors ;(  if  durinjr  tlic  third  Ai\<£,ii  the  uterus  contracts  at  intervals 
(  firmly,  each  contracticMi  being  accompanied  by  blood,  and  yet  on  follow- 
in<i'  Uj)  the  cord  you  feel  the  placenta  in  idrro;  if  on  pulling  on  the 
cord,  TWO  fingers  being  pressed  into  the  placenta  at  the  root,  you  feel 
the  placenta  and  uterus  descend  in  one  mass,  a  sense  of  dragging  pain 
being  elicited;  if  during  a  pain  the  uterine  tumor  does  not  })resent  a 
globular  form,  but  be  more  prominent  than  usual  at  the  place  of  pla- 
cental attachment." ' 

Treatment  of  Adherent  Placenta. — The  artificial  removal  of  an 
adherent  placenta  is  always  a  delicate  and  anxious  operation,  which, 
however  carefully  performed,  must  of  necessity  expose  the  jiaticnt  to 
the  risk  of  injury  to  the  uterine  structures,  and  of  leaving  behind  por- 
tions of  placental  tissue  which  may  give  rise  to  secondary  hemorrhage 
or  septica?mia.  The  cord  Avill  guide  the  hand  to  the  site  of  attachment, 
and  the  fingers  must  be  very  gently  ihsimiated  between  the  lower  edge 
of  the  placenta  and  the  uterine  wall ;  or  if  a  ])ortion  be  already  de- 
tached we  may  commence  to  peel  oif  tlie  remainder  at  that  spot.  Sup- 
porting the  uterus  exterually,  we  carefully  pick  oif  as  much  as  possible, 
proceeding  with  the  greatest  caution,  as  it  is  by  no  means  easy  to  dis- 
tinguish between  the  jjlacenta  and  the  uterus.  At  the  best,  it  is  far 
from  easy  to  remove  all,  and  it  is  wiser  to  separate  only  wliiit  we  read- 
ilv  can  than  to  make  too  protracted  efforts,  at  complete  detachment. 
"SVheu  it  is  found  to  be  impossible  to  detach  and  remove  the  whole  or  a 
great  part  of  the  placenta,  we  cannot  but  look  upon  the  further  j)rog- 
ress  of  the  case  with  considerable  anxiety.  The  retained  portions  may 
be  ere  long  spontaneously  detached  and  expelled,  or  they  may  decom- 
pose and  give  rise  to  fetid  discharge  and  septic  infection.  Such  cases 
must  be  treated  by  antiseptic  intra-uteriue  injections,  so  as  to  lessen  the 
risk  of  absorption  as  much  as  possible;  but  until  the  retained  masses 
have  been  expelled  and  the  discharge  has  ceased  the  patient  must  be 
regarded  as  in  considerable  danger.  (In  a  few  rare  cases  there  is  reason 
to  believe  that  masses  of  retained  placental  tissue  have  been  entirely 
absorbed.  ^  It  is  difficult  to  understand  so  strange  a  phenomenon,  but 
several  well-authenticated  cases  are  recorded  in  Avhich  there  seems  no 
reason  to  doubt  that  the  retained  placenta  was  removed  in  this  Avay.^ 
Various  means  are  used  for  exciting  uterine  contraction  by  reflex 
stimulation.  Amongst  the  most  important  of  these  is  cold.  In  patients 
who  are  not  too  exhausted  to  respond  to  the  stimulus  applied,  it  is  of 
extreme  value.  But  to  be  of  use  it  should  be  used  intermittently  and 
not  continuously.  Pouring  a  stream  of  cold  water  from  a  height  on 
the  abdomen  is  a  not  uncommon,  l)ut  bad  practice,  as  it  deluges  the  pa- 
tient and  the  bedding  in  water,  which  may  afterward  act  injuriously. 
(  Flaj>ping  the  lower  part  of  the  abdomen  with  a  wet  towel  is  less  objec- 
tionable.) '  Ice  can  generally  be  obtained,  and  a  piece  should  be  intro- 
duced into  the  uterus.  This  is  a  very  powerful  haemostatic,  and  often 
excites  strong  action  Mhen  other  means  fail.  I  constantly  employ  it, 
and  have  never  seen  any  bad  results  follow.     A  large  piece  of  ice  i.nay 

'  Obstetric  Operations,  p.  440. 

*See  an  interesting  paper  bv  Dr.  Thrush  on  "  Retention  of  the  Placenta  in  Labor  at 
Term,"  Amcr.  Journ.  of  Obstct'.,  1877,  vol.  x.  pp.  389,  506. 


HEMORRHAGE  AFTER  DELIVERY.  431 

also  be  held  over  the  IiiikIiis,  and  removed  and  reajiplied  from  time  to 
time,  llced  water  may  be  injected  into  the  rectum.  A  very  powerful 
remedy  is  washing  out  the  uterine  cavity  with  a  stream  of  cold  Avater 
by  means  of  the  vaginal  pijjc  of  a  Higginsf)n's  syringe  carried  uj)  to 
the  fundus.  Another  means  of  applying  cold,  said  to  be  very  effectual, 
is  the  application  of  the  ether  spray,  such  as  is  used  for  producing  local 
ana3sthesia,  over  the  lower  part  of  the  abdomen.^  All  these  remedies, 
however,  depend  for  their  good  results  on  the  fact  of  the  patient  being 
in  a  condition  to  respond  to  stinuilus,  and  their  prolonged  use,  if  they 
ftiil  to  excite  contraction  rai)idly,  Avill  certainly  prove  injurious,  Rigby 
used  to  look  upon  the  aj)plication  of  the  child  to  the  breast  as  one  of 
the  most  certain  inciters  of  uterine  action.  It  may  be  of  service  after 
the  hemorrhage  has  been  checked  in  keeping  up  tonic  contraction,  and 
should  therefore  not  be  omitted ;  but  we  certainly  cannot  waste  time  in 
inducing  the  child  to  suck  in  the  face  of  the  actual  emergency. 

Of  late,  intra-uterine  injections  of  hot  water  at  a  temperature  of 
from  100°  to  120°  have  been  highly  recommended  as  a  powerful  means 
of  arresting  post-partum  hemorrhage,  often  proving  effectual  when  all 
other  treatment  has  failed.  The  number  of  published  cases  in  which  it 
has  proved  of  great  value  is  now  considerable.  The  present  master  of 
the  Rotunda,  Dr.  Lombe  Atthill,  has  recorded  16  cases  ^  in  which  it 
checked  hemorrhage  at  once,  in  many  of  which  ergot,  ice,  and  other 
means  had  failed.  He  speaks  of  it  as  especially  useful  in  those  trouble- 
some cases  in  which  the  uterus  alternately  relaxes  and  hardens,  and 
resists  all  our  efforts  to  produce  permanent  contraction.  Its  superiority 
to  cold  water  has  been  well  shown  by  Milne  Murray^  by  means  of 
experiments  on  pregnant  and  non-pregnant  rabbits,  which  proved  that 
while  cold  applications  produce  a  temporary  contraction,  when  applied 
for  any  length  of  time  they  rapidly  exhaust  the  excitability  of  the  ute- 
rine muscle,  while  the  reverse  effect  is  produced  when  hot  water  is  used. 
^My  own  experience  of  this  treatment  is  very  favorable.  I  I  have  now 
used  it  in  several  cases,  in  some  of  which  the  tendency  to  hemorrhage 
was  very  great,  and  in  every  instance  it  has  at  once  produced  strong 
uterine  action  and  instantly  checked  the  flow.  It  is,  moreover,  much 
more  agreeable  to  the  patient  than  cold  applications.  I  think  it  cannot 
be  doubted  that  we  have  in  these  warm  irrigations  a  valuable  addition 
to  our  methods  of  treating  uterine  hemorrhage.  [Hot-water  injections, 
to  be  effective,  should  have  a  temperature  of  about  115°.  Water  simply 
warm — that  is,  only  a  little  above  blood-heat — favors  the  hemorrhagic 
loss. — Ed.] 

The  late  Dr.  Earlc  pointed  out*  that  a  distended  bladder  often  pre- 
vents contraction,  and  to  avoid  the  possibility  of  this  the  catheter 
should  be  passed. 

Plugging  of  the  vagina  has  often  been  used.  It  is  only  ncecssarv  to 
mention  it  for  the  purpose  of  insisting  on  its  absolute  inappljcjij )i I i ix  in 
all  cases  of  post-partum  hemorrhage ;  the  only  effect  it  could  have 
would  be  to  prevent  the  escape  of  blood  externally,  which  might  then 
collect  to  any  extent  in  the  cavity  of  the  uterus. 

'  Griffiths,  Practitioner,  1877,  vol.  xviii.  p.  176.  '  Lancet,  Febrnarv  9,  1878. 

3  Edin.  Med.  Journ.,  1886-87,  pp.  131,  215.         *  Earle's  Flooding  after  Delivery,  p.  163. 


432  LABOR. 

Copipressign  of  tlie  abdominal  aorta  is  liiglily  tliought  of  by  many 
continental  authorities,  but  it  is  little  known  or  practised  in  Eng'land. 
It  lias  been  objected  to  by  some  on  the  theoretical  ground  that  the  iiem- 
orrhage  is  chiefly  venous,  and  not  arterial,  and  that  it  Avould  only  favor 
the  reflux  of  venous  blood  into  the  vena  cava.  Cazeaux  points  out  that 
on  account  of  the  close  anatomical  relations  between  the  aorta  and  the 
vena  cava  it  is  hardly  possible  to  compress  one  vessel  without  the  other. 
The  backward  flo\v  of  blood,  therefore,  through  the  vena  cava  may  also 
be  thus  arrested.  (There  is  strong  evidence  in  favor  of  the  occasional 
utility  of  compression.  Its  chief  recommendation  is  that  it  can  Ije  prac- 
tised immediately,  and  by  an  assistant  who  can  be  shown  how  to  iipply 
the  pressure. '  It  is  most  likely  to  prove  useful  in  sudden  and  severe 
hemorrhage,  and  if  it  only  control  the  loss  for  a  few  moments  it  gives 
us  time  to  apply  other  methods  of  treatment.  As  a  temjiorary  expedi- 
ent, therefore,  it  should  be  borne  in  mind  and  adopted  when  necessary. 
It  has  the  great  advantage  of  supplementing,  without  superseding,  other 
and  more  radical  plans  of  treatment.  The  pressure  is  very  easily 
applied,  on  account  of  the  lax  state  of  the  abdominal  walls.  The  artery 
can  readily  be  felt  pulsating  above  the  fundus  uteri,  and  can  be  com- 
pressed against  the  vertebras  by  three  or  four  fingers  applied  lengthways. 
Baudelocque,  who  was  a  strong  advocate  of  this  procedure,  stated  that 
he  had  on  several  occasions  controlled  an  otherwise  intractable  hemor- 
rhage in  this  way,  and  that  he  on  one  occasion  kept  up  compression  for 
four  consecutive  hours.,  Cazeaux  believes  that  compression  of  the  aorta 
may  have  a  further  advantageous  effect  in  retaining  the  mass  of  the 
blood  in  the  upper  part  of  the  body,  and  thus  lessening  the  tendency  to 
syncope  and  collapse.  If  an  aortic  tourniquet,  such  as  is  used  for  com- 
pressing the  vessel  in  cases  of  aneurism,  could  be  obtained,  it  might  be 
used  with  advantage  in  such  cases. 

If  a  battery  is  at  hand  the  faradic  current  may  be  used,  and  is,  it  is 
said,  a  very  powerful  agent  in  inducing  uterine  contraction,  one  pole 
being  introduced  into  the  uterus,  the  other  applied  over  it  through  the 
abdominal  ]:)arietes. 

When  the  hemorrhage  has  been  excessive  and  there  is  jirofound 
exhaustion,  firm  bandaging  of  the  extremities,  by  preference  with 
Esmarch's  elastic  bandages  if  they  can  be  obtained,  may  be  advanta- 
geousl\-  adopted,  with  the  view  of  retaining  the  blood  as  much  as  pos- 
sible in  the  trunk,  and  thus  lessening  the  tendency  to  syncope.  xVs  a 
temporary  expedient  in  the  worst  class  of  cases  it  may  occasionally  prove 
of  service. 

[Lives  of  patients  in  extremis  have  been  saved  by  the  expedient  of 
raising  the  body  of  the  woman  and  lowering  her  head,  so  as  to  turn  the 
current  of  blood  toward  the  brain.  This  may  have  to  be  repeated  sev- 
eral times  in  the  treatment  of  a  case  where  attacks  of  syncope  indicate 
it.  A  bladder  containing  ice  may  be  held  under  the  hand  of  the  ope- 
rator over  the  abdomen  and  above  the  fundus  uteri,  and  compression 
made  upon  the  uterus  and  aorta  at  the  same  time.  In  one  case  I  was 
forced,  by  the  long-continued  inertia  of  the  uterus  and  the  tendency  to 
a  return  of  hemorrhage,  to  keep  up  this  form  of  compression  for  six  and 
a  half  hours.     The  hand  of  the  operator  should  be  protected  by  a  com- 


HEMORRHAGE  AFTER  DELIVERY.  433 

press  of  flannel,  or  he  may  have  an  attack  of  local  neuralgia,  or  possibly 
rheumatism,  in  his  arm. — Ed.] 

Supposing  these  means  fail,  and. the  uterus  obstinately  refuses  to  con- 
tract in  spite  of  all  our  efforts — and,  do  what  we  may,  cases  of  this  kind 
will  occur — the  only  other  agent  at  our  command  is  the  application  of 
a  pcMfirfuLsty^tic  to  the  bleeding  surface  to  produce  thrombosis  in  the 
vessels.  "  The  latter,"  says  Dr.  Ferguson,*  alluding  to  this  means  of 
arresting  hemorrhage,  "  appears  to  be  the  sole  means  of  safety  in  those 
cases  of  intense  flooding  in  which  the  uterus  flaps  about  the  hand  like 
a  wet  towel.  Incapable  of  contraction  for  hours,  yet  ceasing  to  ooze  out 
a  drop  of  blood,  there  is  nothing  apparently  between  life  and  death  but 
a  few  soft  coagula  plugging  up  the  sinuses."  These  form  but  a  frail 
barrier  indeed,  but  the  experience  of  all  who  have  used  the  injection  of  f 
perch loride  of  iron  in  such  cases  proves  that  they  are  thoroughly  effec- 
tual, and  their  introduction  into  practice  is  one  of  the  greatest  improve- 
ments in  modern  midwifery.  Although  this  method  of  treating  these 
obstinate  cases  is  not  new,  since  it  was  practised  long  ago  in  Germany, 
its  adoption  in  England  is  unquestionably  due  to  the  energetic  recom- 
mendation of  Dr.  Barnes.  Although  the  dangers  of  the  practice  have 
been  strongly  insisted  on,  and  with  a  degree  of  acrimony  that  is  to  be 
regretted,  I  know  of  only  one  published  case  in  which  its  use  has  been 
followed  by  any  evil  effects.  Its  extraordinary  power,  however,  of 
instantly  checking  the  most  formidable  hemorrhage  has  been  demon- 
strated by  the  unanimous  testimony  of  all  who  have  tried  it.  As  it  is 
not  proposed  by  any  one  that  this  means  of  treatment  should  be  employed 
until  all  ordinary  methods  of  evoking  contraction  have  failed,  and  as  in 
cases  of  this  kind  the  lives  of  the  patients  are  of  necessity  imperilled, 
we  should  be  fully  justified  in  adopting  it,  even  if  its  possibly  injurious 
effects  had  been  much  more  certainly  proved.  It  is  surely  at  any  time 
justifiable  to  avoid  a  great  and  pressing  peril  by  running  a  possible 
chance  of  a  less  one.  Whenever,  therefore,  we  have  tried  the  plans 
above  indicated  in  vain,  no  time  should  be  lost  in  resorting  to  this  expe- 
dient. No  practitioner  should  attend  a  case  of  midwifery  without  hav- 
ing the  necessary  styptic  with  him.  /  The  best  and  most  easily  obtain- 
able form  of  using  the  remedy  is  the  "  liquor  ferri  perchloridi  fortior  " 
of  the  London  Pharmacopoeia,  which  should  be  diluted  for  use  with  six 
times  its  bulk  of  water.  \  This  is  certainly  better  thana  weaker  solution. 
The  vaginal  pipe  of  a  Higginson's  syringe,  through  which  the  solution 
has  once  or  twice  been  pumped  to  exclude  the  air,  is  guided  by  the  hand 
to  the  fundus  uteri  and  the  fluid  injected  gently  over  the  uterine  surface. 
The  loose  and  flabby  mucous  membrane  is  instantaneously  felt  to  pucker 
up,  all  the  blood  with  which  the  fluid  comes  in  contact  is  coagulated, 
and  the  hemorrhage  is  immediately  arrested.  \  I  think  it  is  of  import- 
ance to  make  sure  that  the  uterus  and  vagina  are  emptied  of  clots  before 
injection.  In  the  only  cases  in  which  I  have  seen  any  bad  symptoms 
follow  this  precaution  had  been  neglected.)  The  iron  hardened  all  the 
coagula,  which  had  remained  in  utero,  and  septicaemia  supervened ; 
Avhich,  however,  disappeared  after  the  clots  had  been  broken  up  and 
washed  away  by  intra-uterine  antiseptic   injections.     After  we  have 

'  Preface  to  Gooch  On  Diseases  of  Women,  p.  xlii.,  New  Sydenham  Society,  1859. 

28 


434  LABOR. 

,   if.sortocl  to  this  treatineut  all   lurtlicr  prcs-siirc  (»n   tlie  uterus  slioukl  l)e 

\  stopped.      We  must  renieuiber  that  we  have  now  abandoned  eontiaetion 

as  a  haemostatic,  and  are  trusting  to  throndmsis,  and  that  ])ressure  inijrht 

detach   and   loosen   the  coagula   Avhich  are  preventing  the  escape    <»f 

blood. 

Other  local  astringents  may  l)o  eventually  found  to  he  of  use.  Tinc- 
ture of  matico  jjossibly  might  l)e  serviceable,  although  I  am  not  aware 
that  it  has  been  tried.  Dupierris  has  advocated  tincture  of  icxline, 
and  has  recorded  24  cases  in  which  he  employed  it,  in  all  without  acci- 
dcnt  and  with  a  successful  issue.  Penrose  strongly  recommends  coni- 
mon  vinegar,  which  has  the  advantage  of  being  alwavs  readilv  obtain- 
able.p]  But  nothing  seems  likely  to  act  so  innnediately  or  so  effectu- 
ally as  the  perchloride  of  iron. 

Hemorrhage  from  Laceration  of  Maternal  Structures. — A  word 
may  here  be  said  as  to  the  occasional  dependence  of  hemori'hage  after 
delivery  on  laceration  of  the  cervix  or  other  injury  to  the  maternal  soft 
parts.  Duncan  has  narrated  a  case  in  which  the  bleeding  came  from  a 
ruptured  perineum.  If  hemorrhage  continue  after  the  uterus  is  per- 
manently contracted,  a  careful  examination  should  be  made  to  ascertain 
if  any  such  injury  exist.Y  Most  generally  the  source  of  bleeding  is  the 
cervix,  and  the  flow  can  be  readily  arrested  by  swabbing  the  injured 
textures  with  a  sponge  saturated  in  a  solution  of  the  perchloride.' 

The  secondary  treatment  of  post-partum  hemorrhage  is  of  import- 
ance. When  reaction  commences  a  train  of  distressing  symptoms  often 
show  themselves,  such  as  intense  and  throbbing  headache,  great  intoler- 
ance of  light  and  sound,  and  general  nervous  prostration ;  and  when 
these  have  passed  away  we  have  to  deal  with  the  more  chronic  effects 
of  profuse  loss  of  blood.  Nothing  is  so  valuable  in  relieving  these 
symptoms  as  opium.  It  is  the  best  restorative  that  can  be  employed, 
but  it  must  m  'administered  in  larger  doses  than  usual.  Thirty  to 
forty  drops  of  Battley's  solution  should  be  given  by  the  mouth  or  in 
an  enema.  At  the  same  time  the  patient  should  be  kept  perfectly  still 
and  (|uiet  in  a  darkened  room,  and  the  visits  of  anxious  friends  strictly 
forbidden.  Strong  beef-essence  or  gravy  soup,  milk,  or  eggs  beaten  uj) 
with  milk,  and  similar  easily  absorbed  articles  of  diet,  should  be  given 
frequently  and  in  small  quantities  at  a  time.  Stimulants  will  be  required 
according  to  the  state  of  the  patient,  such  as  warm  brandy-and-water, 
port  wine,  etc.  Rggtlo  l^ed  should  be  insisted  on,  and  continued  nuich 
beyond  the  usual  time.  Eventually,  the  remedies  which  act  by  promot- 
ing the  formation  of  blood,  such  as  the  various  preparations  of  irgu, 
will  be  found  useful,  and  may  be  required  for  a  length  of  time. 

Under  the  head  of  Transfusion  I  have  separately  ti'eated  the  applica- 
tion of  that  last  resource  in  those  desperate  cases  in  which  the  loss  of 
blood  has  been  so  excessive  as  to  leave  no  other  hope. 

Secondary  Post-partum  Hemorrhag-e. — In  the  majority  of  cases, 
if  a  few  hours  have  ela])sed  after  delivery  without  hemorrhage  we  may 
consider  the  patient  safe  from  the  accident.     It  is  by  no  means  very 

['This  remedy  was  used  as  a  uterine  injection  witli  signal  effect  in  a  case  of  violent 
ixjst-parium  heniorrhatre  by  a  Frencli  surgeon  in  country  practice  in  ilie  days  of  Astnic, 
who  wrote  of  it  in  170-3  {Slakuliv^  d>:.-<  Fcmmo^,  vol.  iv.  p.  227  i. — Ed.] 


HEMORRHAGE  AFTER  DELIVERY.  435 

rare,  however,  to  meet  witli  even  profuse  losses  of  blood  coming  on  in 
the  course  of  convalescence  at  a  time  varying  from  a  few  hours  or  days 
up  to  several  weeks  after  delivery.  These  cases  are  described  as  exam- 
ples of  ^^  secondary  hoiiorrliafjej"  and  they  have  not  received  at  all  an 
adequate  amount  of  attention  from  obstetric  writers,  inasmuch  as  they 
often  give  rise  to  very  serious,  and  even  fatal,  results,  and  are  always 
somewhat  obscure  in  their  etiology  and  difficult  to  treat.  We  owe 
almost  all  our  knowledge  of  this  condition  to  an  excellent  paper  by  Dr. 
McClintock  of  Dublin,  who  has  collected  characteristic  examples  from 
the  writings  of  various  authors,  and  accurately  described  the  causes 
Avhich  are  most  apt  to  produce  it. 

(jVe  must,  in  the  first  place,  distinguish  between  true  secondary  hemor- 
rhage and  profuse  lochial  discharge  continued  for  a  longer  time  than 
usual. )  The  latter  is  not  a  very  uncommon  occurrence,  and  is  generally 
met  with  in  cases  in  which  involution  of  the  uterus  has  been  checked, 
as  by  too  early  exertion,  general  debility,  and  the  like.  The  amount 
of  the  lochial  discharge  varies  in  different  women.  In  some  patients 
it  habitually  continues  during  the  whole  puerperal  month,  and  even 
longer,  but  not  to  an  extent  which  justifies  us  in  including  it  under 
the  head  of  hemorrhage.  ( In  such  cases  prolonged  rest,  avoidance  of 
the  erect  posture,  occasional  small  doses  of  ergot,  and,  it  may  be,  after 
the  lapse  of  some  weeks  astringent  injections  of  oak-bark  or  aTum,  will 
be  all  that  is  necessary  in  the  way  of  treatment./ 

True  secondary  hemorrhage  is  often  sudden  in  its  appearance  and 
serious  in  its  effects.  McClintock  mentions  6  fatal  cases,  and  Mr. 
Bassett  of  Birmingham^  has  recorded  13  examples  which  came  under 
his  own  observation,  2  of  which  ended  fatally. 

The  causes  may  be  either  constitutional  or  some  local  condition  of 
the  uterus  itself. 

Constitutional  Causes. — Among  the  former  are  such  as  produce  a 
•disturbance  of  the  vascular  system  of  the  body  generally  or  of  the 
uterine  vessels  in  particular.  The  state  of  the  uterine  sinuses,  and 
the  slight  barrier  Avhich  the  thrombi  formed  in  them  offer  to  the 
escape  of  blood,  readily  explain  the  fact  of  any  sudden  vascular  con- 
gestion producing  hemorrhage.  Thus,  mental  emotions,  the  sudden 
assmiiption  of  the  erect_,^osture,  any  undue  exertion,  the  incautious 
use  of  stimulants,  a  loaded  condition  of  the  bowels,  or  sexual  inter- 
course shortly  after  delivery,  may  act  in  this  way.^  McClintock  records 
the  case  of  a  lady  in  whom  very  profuse  hemorrhage  occurred  on  the 
twelfth  day  after  labor,  when  sitting  up  for  the  first  time.  Feeling 
faint  after  suckling,  the  nurse  gave  her  some  brandy,  whereupon  a  gush 
of  blood  ensued,  "  deluging  all  the  bed-clothes  and  penetrating  through 
the  mattress  so  as  to  form  a  pool  on  the  floor."  Here  the  erect  position, 
the  exquisite  pain  caused  by  nursing,  and  the  stimulating  drink,  all 
concurred  to  excite  the  hemorrhage.  In  another  instance  the  flooding 
Avas  traced  to  excitement  produced  by  the  sudden  return  of  an  old  lover 
on  the  eighth  day  after  labor.  Moreau  especially  dwells  on  the  influ- 
ence of  local  congestion  produced  by  a  loaded  condition  of  the  rectum. 
Constitutional  affections,  producing  general  debility  and  an  impover- 

1  Brit.  Med.  Journ.,  1872,  vol.  ii.  pp.  216,  491. 


436  LABOR. 

islit'd  state  of  the  hlood,  probably  also  may  have  the  same  effect.  Blot 
S})ecial!y  mentions  albiiiiiinmia  as  one  of  these,  and  Saboia  states  that 
in  JJra/il  secondary  hemorrhage  is  a  common  symptom  of  miasmatic 
j)oisonin<^,  and  can  only  be  cured  by  change  of  air  and  the  free  use  of 
quinine.' 

Local  Causes. — I^ocal  conditions  seem,  however,  to  be  the  more  fre- 
quent factors  in  the  ])r(»duction  of  sec(jndary  hemorrliage.  These  mav 
be  generally  classed   under  the  following  heads: 

1.  Irregular  and  inefficient  contraction  of  the  uterus. 

2.  Clots  in  the  uterine  cavity. 

3.  Portions  of  retained  placenta  or  membranes. 

4.  Retroflexiou  of  the  uterus. 

5.  Laceration  or  inflammatory  state  of  the  cervix. 

6.  Thrombosis  or  luematocele  of  the  cervix  or  vulva. 

7.  Inversion  of  the  uterus. 

8.  Fibroid  tumors  or  polypus  of  the  uteras. 

The  first  four  of  these  need  only  now  be  considered,  the  others  being 
described  elsewhere. 

Relaxation  of  the,  uterus  and  distension  of  its  cavity  by  coagula  may 
give  rise  to  hemorrhage,  although  not  so  readily  as  immediately  after 
delivery,  for  coagula  of  consideral^le  size  are  often  retained  in  utero  for 
many  days  after  labor.  The  uterus  will  be  found  larger  than  it  ought 
to  be,  and  tender  on  pressure.  Usually  the  coagula  are  expelled  with 
severe  after-pains;  but  this  may  not  take  place,  and  hemorrhage  may 
ensue  several  days  after  delivery.  Or  there  may  be  only  a  relaxed  state 
of  the  uterus  without  retained  coagula.  Bassett  relates  4  cases  traced 
to  these  causes,  and  several  illustrations  will  be  found  in  McC'lintock's 
paper.  Portions  of  retained  placenta  or  membranes  are  more  fre(|uent 
causes.  The  retention  may  be  due  to  carelessness  on  the  part  of  the 
practitioner,  especially  if  he  have  removed  the  placenta  by  traction  and 
failed  to  satisfy  himself  of  its  integrity.  It  may,  however,  often  be 
due  to  circumstances  entirely  beyond  his  control,  such  as  adherent  pla- 
centa, which  it  is  impossible  to  n.move  \\ithout  leaving  portions  in  iitcro, 
or  more  rarely  placenta  succenturia.  (  In  the  latter  case  there  is  a  small 
supplementary  portion  of  placental  tissue  developed  entirely  separate 
from  the  general  mass,  and  it  may  remain  in  utero  without  the  j)rac- 
titioner  having  the  least  suspicion  of  its  existence,;  Portions  of  the 
membranes  are  veiy  apt  to  be  left  in  utero.  It  is  to  prevent  this  that 
they  should  be  twisted  into  a  rope  and  extracted  very  gently  after 
expression  of  the  ]>lacenta.  Hemorrhage  from  these  causes  generally 
does  not  occur  until  at  least  a  Aveek  after  deliver}',  and  it  may  not  do 
so  until  a  nuich  longer  time  has  elapsed.  In  4  cases  recorded  by  Mr. 
Bassett  it  commenced  on  the  tenth,  twelfth,  fourteenth,  and  thirty-second 
day.  It  may  come  on  suddenly,  and  continue,  or  it  may  stop,  and  recur 
frequently  at  short  intervals.  In  my  experience  retention  of  portions 
of  the  placenta  is  very  common  after  abortion,  when  adhesions  are  more 
generally  met  with  than  at  term.  In  addition  to  the  hemorrhage  there 
is  often  a  fetid  discharge,  due  to  decomposition  of  the  retained  portion, 
and  possibly  more  or  less  marked  septicfcmic  symptoms,  which  may  aid 
'  Saboia,  Traite  des  Accouchemeiits,  p.  819. 


HEMORRHAGE  AFTER  DELIVERY.  437 

iu  the  diagnosis.  The  placenta  or  membranes  may  simply  be  lying 
loose  as  foreign  bodies  in  the  uterine  cavity,  or  they  may  be  organi- 
cally attached  to  the  uterine  walls,  when  their  removal  will  not  be  so 
easily  effected. 

Barnes  has  especially  pointed  out  the  influence  of  retroflexion  of  the 
uterus  in  producing  secondary  hemorrhage/  which  seems  to  act  by  im- 
peding the  circulation  at  the  point  of  flexion  and  thus  arresting  the  pro- 
cess of  invt)lution. 

Treatment. — In  every  case  in  which  secondary  hemorrhage  occurs  to 
any  extent,  careful  investigation  into  the  possible  causes  of  the  attack  and 
an  accurate  vaginal  examinatiijn  are  imperatively  required.  If  it  be  due 
to  general  and  constitutional  causes  only,  we  must  insist  on  the  most 
absolute  rest  on  a  hard  bed  in  a  cool  room,  and  on  the  absence  of 
all  causes  of  excitement.  The  liquid  extract  of  ergot  will  be  very  gen- 
erally useful  in  sj  doses  repeated  every  six  hours.  McCliutock  strongly 
recommends  the  tinctiire  of  Indiau  hemp,  which  may  be  advantageously 
combined  with  the  ergot  iu  doses  of  10  or  15  minims,  suspended  in 
mucilage.  Astringent  vaginal  pessaries  of  matico  or  perchloride  of  iron 
may  be  used.  Special  attention  should  be  paid  to  the  state  of  the 
bowels,  and  if  the  rectum  be  loaded  it  should  be  emptied  by  ene- 
niata.  In  more  chronic  cases  a  mixture  of  ergot,  sulphate  of  iron, 
and  small  doses  of  sulphate  of  magnesia  will  prove  very  serviceable. 
This  is  more  likely  to  be  effectual  when  the  bleeding  is  of  an  atonic 
and  passive  character.  McCliutock  speaks  strongly  in  favor  of  the 
application  of  a  blister  over  the  sacrum.  When  the  hemorrhage  is  ex- 
cessive more  effectual  local  treatment  will  be  required.  Cazeaux  advises 
plugging  of  the  vagina.  Although  this  cannot  be  considered  so 
dangerous  as  immediately  after  delivery,  inasmuch  as  the  uterus  is 
not  so  likely  to  dilate  above  the  plug,  still  it  is  certainly  not  entirely 
without  risk  of  favoring  concealed  internal  hemorrhage.  If  it  be  used 
at  all,  a  firm  abdominal  pad  should  be  applied,  so  as  to  compress 
the  uterus,  and  the  abdomen  should  be  examined  from  time  to  time 
to  ensure  against  the  possibility  of  uterine  dilatation.  AVith  these  pre-, 
cautions  the  plug  may  prove  of  real  value.  [In  any  case  of  really 
alarming  hemorrhage  I  should  be  disposed  rather  to  trust  to  the  ap- 
plication of  styptics  to  the  uterine  cavity)  The  injection  of  fluid  in 
bulk,  as  after  delivery,  could  not  be  safely  practised,  on  account  of  the 
closure  of  the  os  and  the  contraction  of  the  uterus.  But  there  can  be 
no  objection  to  swabbing  out  the  uterine  cavity  with  a  small  piece  of 
sponge  attached  to  a  handle  and  saturated  in  a  solution  of  the  perchlo- 
ride of  iron.     There  are  few  cases  which  Avill  resist  this  treatment. 

If  we  have  reason  to  suspect  retained  placenta  or  membranes,  or  if  the 
hemorrhage  continue  or  recur  after  treatment,  a  careful  exploration  of 
the  interior  of  the  womb  will  be  essential.  On  vaginal  examination  we 
may  possibly  feel  a  portion  of  the  ])lacenta  ])rotruding  through  the  os, 
which  cau  then  be  removed  without  difficulty.  If  the  os  be  closed,  it 
must  be  dilated  with  sjionge  or  lamiuaria  tents  or  by  a  small-sized 
Barnes  bag,  and  the  uterus  can  then  be  thoroughly  explored.  This 
ought  to  be  done  under  chloroform,  as  it  cannot  be  efiectually  accom- 

^  Obdelric  Operations,  p.  492. 


438  LABOR. 

j)lislietl  without  intrtKliiciiio-  the  wliolc  liaiul  into  the  vagina,  wiiicli 
necessarily  causes  much  ])ain.  If  the  placenta  or  membranes  be  locjse 
ill  tile  uterine  cavity,  they  may  be  removed  at  once,  or  if  tiuy  be  organ- 
ically attached,  they  may  be  carefully  picked  olf.  The  uterus  should  at 
tiic  same  time,  as  loiiii;  as  the  os  remains  ])atulous,  be  thorouglily 
wasiied  out  with  Condy's  Huid  and  water  to  diminish  the  risk  of 
septicaemia. 

Retroflexion  can  readily  be  detected  by  vaginal  examination,  and  the 
treatment  consists  in  careful  reposition  with  the  hand  and  the  application 
of  a  large-sized  Hodge's  pe&sary. 


CHAPTER   XVI. 

RUPTUKE  OF  THE  UTERUS,  ETC. 

Rupture  of  the  uterus  is  one  of  the  most  dangerous  accidents  of 
lal)or,  and  until  of  late  years  it  has  been  considered  almost  necessarily 
fatal  and  beyond  the  reach  of  treatment.  Fortunately,  it  is  not  of  very 
frequent  occurrence,  although  the  j)ublished  statistics  vary  so  much  that 
it  is  by  no  means  easy  to  arrive  at  any  conclusion  on  this  point.  The 
exjjlanation  is,  no  doubt,  that  many  of  the  tables  confound  partial  and 
com})aratively  unimportant  lacerations  of  the  cervix  and  vagina  with 
rupture  of  the  body  and  fundus.  It  is  only  in  large  lying-in  institu- 
tions, where  the  results  of  cases  are  accurately  recorded,  that  anything 
like  reliable  statistics  can  be  gathered,  for  in  private  practice  the  occur- 
rence of  so  lamentable  an  accident  is  likely  to  remain  uin)ublished.  To 
show  the  difference  between  the  figures  given  by  authorities,  it  may  be 
stated  that,  while  Burns  calculates  the  projiortion  to  be  1  in  940  labors, 
Ingleby  fixes  it  as  1  in  1300  or  1400,  Churchill  as  1  in  1331,  and  Leh- 
mann  as  1  in  2433.  Dr.  Jolly  of  Paris  has  jaiblished  an  excellent 
thesis  containing  much  valuable  information.^  He  finds  that  out  of 
782,741  labors,  230  ruptures,  excluding  those  of  the  vagina  or  cervix, 
occurred — that  is,  1  in  3403. 

Ijacerations  may~occur  in  any  part  of  the  uterus — the  fundus,  the 
body,  or  the  cervix.  ^ Those  of  the  cervixlu'e  comjiaratively  of  small 
consequence,  and  occur,  to  a  slight  extent,  in  almost  all  first  laboi-s.^ 
Only  those  which  involve  the  sujiravaginal  jiortion  are  of  really  serious 
im})ort.  Ruptures  of  the  upper  part  of  the  uterus  are  much  less  frequent 
than  of  the  portion  near  the  cervix  ;  partly,  no  doubt,  liecause  the  fundus 
is  beyond  the  reach  of  the  mechanical  causes  to  which  the  accident  can, 
not  unfrequently,  be  traced,  and  jiartly  because  the  lower  third  of  the 
organ  is  apt  to  be  compressed  between  the  jircscnting  ])art  and  the  bony 
pelvis.    (The  site  of  placenU\l..i.ngg.rtlun  is  said  by  i\Iadame  La  Chapelle 

'  Rupture  uterine  pendant  le  Travail,  Pai'is,  1873. 


RUPTURE  OF  THE   UTERUS,  ETC.  439 

to  be  rarely  involved  in  the  rupture,  but  it  does  not  always  eseape,  as 
inimerous  recorded  cases  prove. jfThe  most  frequent  seat  of  rupture  is 
near  the  junction  of  the  body  and  neck,  either  anteriorly  or  posteriorly^ 
opposite  the  sacrum,  or  behind  the  syni])hysis  pubis,  but  it  may  occur  at 
the  sides  of  the  lower  segment  of  the  uterus.  In  some  cases  the  entire 
cervix  has  been  torn  away,  and  separated  in  the  form  of  a  ring.\ 

The  laceration  may  be  partial  or  complete,  the  latter  being  the  more 
common.  The  muscular  tissue  alone  may  be  torn,  the  peritoneal  coat 
remaining  intact ;  or  the  converse  may  occur,  and  then  the  peritoneum 
is  often  fissured  in  various  directions,  the  muscular  coat  being  unimpli- 
cated.  The  extent  of  the  injury  is  very  variable,  in  some  cases  being 
only  a  slight  tear,  in  others  forming  a  large  aperture,  sufficiently  exten- 
sive to  allow  the  foetus  to  pass  into  the  abdominal  cavity.  The  direction 
of  the  laceration  is  as  variable  as  the  size,  but  it  is  more  frequently  vei'- 
tical  than  transverse  or  oblique.  The  edges  of  the  tear  are  irregular  and 
jagged ;  probably  on  account  of  the  contraction  of  the  muscular  fibres, 
which  are  frequently  softened,  infiltrated  with  blood,  and  even  gangren- 
ous. Large  quantities  of  extravasated  blood  will  be  found  in  the  perito- 
ueal  cavity;  such  hemorrhage,  indeed,  being  one  of  the  most  important 
sources  of  danger. 

The  causes  are  divided  into  predisposing  and  exciting ;  and  the  prog- 
ress of  modern  research  tends  more  and  more  to  the  conclusion  that  the 
cause  which  leads  to  the  laceration  could  only  have  operated  because  the 
tissue  of  the  uterus  was  in  a  state  predisposed  to  rupture,  and  that  it 
would  have  had  no  such  effect  on  a  perfectly  healthy  organ.  What 
these  predisposing  changes  are,  and  how  they  operate,  is  yet  far  from 
being  known,  and  the  subject  offers  a  fruitful  field  for  pathological 
investigation. 

'  It  is  generally  believed  that  lacerations  are  more  common  in  mul- 
tiparse  than  in  primiparse.  Tyler  Smith  contended  that  ruptures  are 
relatively  as  common  in  first  as  in  subsequent  labors,  while  Bandl  ^  found 
that  only  64  cases  out  of  546  ruptures  were  in  primiparte.  Statistics 
are  not  sufficiently  accurate  or  extensive  to  justify  a  positive  conclusion, 
but  it  is  reasonable  to  suppose  that  the  pathological  changes  presently  to 
be  mentioned  as  predisposing  to  laceration  are  more  likely  to  be  metAvith 
in  women  whose  uteri  have  frequently  undergone  the  alteration  attend- 
ant on  repeated  pregnancies,  i^e  seems  to  have  considerable  influence, 
as  a  large  proportion  of  cases  have  occurred  in  women  between  thirty  and 
forty  years  of  age. 

Alterations  in  the  tissues  of  the  uterus  are  probably  of  very  great 
importance  in  predisposing  to  the  accident,  although  our  information  on 
this  point  is  far  from  accurate.  Among  these  are  morbid  states  of  the 
muscular  fibres,  the  result  of  blows  and  coirtusions  during  pregnancy ; 
premature  fatty  degeneration  of  the  muscular  tissues,  an  anticipation,  as 
it  were,  of  the  normal  involution  after  delivery;  fibroid  tumors  or  malig- 
nant infiltration  of  the  uterine  walls,  which  either  produce  a  morbid  state 
of  the  tissues  or  act  as  an  impediment  to  the  expulsion  of  the  ftx-tus. 
The  importance  of  such  changes  has  been  specially  dwelt  on  by  ]\Iur- 
pliy  in  this  country  and  by  Lehmann  in  Germany,  and  it  is  impossible 

'  ZTebcr  Ruptur  der  Gcbdrmuiier,  Wien,  1815. 


440  LABOR. 

not  to  oonceJo  their  j)robable  iiilliRMuc  in  favorin*::  laceration.  How- 
ever, as  yet  these  views  are  Ibuucled  more  on  reasonable  hypothesis  than 
«n  accurately  oljserved  pathological  facts. 

Another  and  very  iMi])ortant  class  of  predisposing  causes  are  those 
which  lead  to  a  want  of  proper  jirojjortion  between  the  pelvis  and  the 
fictus. 

Deformity  of  the  pelvis  has  been  very  frequently  met  with  in  cases 
in  which  the  uterus  has  ruptured.  Thus,  out  of  19  ca-^es  carefully 
recorded  by  Radford,"  the  pelvis  was  contracted  in  11,  or  more  than  one- 
half.  (  Radford  makes  the  curious  observation  that  ruptures  seem  more 
likely  to  occur  when  the  deformity  is  only  slight,  and  he  explains  this 
by  supposing  that  in  slight  deformities  the  lower  segment  of  the  uterus 
engages  in  the  brim,  and  is  therefore  much  subjected  to  compression, 
while  in  extreme  deformity  the  os  and  cervix  uteri  remain  above  the 
brim,  the  body  and  fundus  of  the  uteiais  hanging  down  between  the 
thighs  of  the  mother.  This  explanation  is  reasonable,  but  the  rarity  with 
which  ruptured  uterus  is  associated  with  extreme  pelvic  deformity  may 
rather  depend  on  the  iufrequency  of  advanced  degrees  of  contraction. 

Bandl,  who  has  made  the  most  important  of  modern  contributions  to 
our  knowledge  of  the  subject,  points  out  thatl  rupture  nearly  always 
begins  in  the  lower  segment  of  the  uterus,  which  becomes  abnormally 
stretched  and  distended  when  from  any  cause  the  expulsion  of  the 
foetus  is  delayed.)  The  upper  portion  of  the  uterus  becomes  at  the 
same  time  retracted  and  much  thickened.  (See  Fig.  150.)  As  the  pains 
continue,  the  stretching  of  the  lower  segment,  called  by  Spiegelberg 
;,  the  "  obstetrical  cervix,"  becomes  more  and  more  marked  until  at  last 
'  its  fibres  separate  and  a  laceration  is  established.  The  line  of  demar- 
cation })etween  the  thickened  body  and  the  distended  lower  segment, 
known  as  the  ring  of  Bandl,  can  in  such  cases  be  occasionally  made  out 
by  palpation  above  the  pubes. 

Amongst  causes  of  disproportion  depending  on  the  foetus  are  either 
malpresentation,  in  which  the  pains  cannot  eifect  expulsion,  or  undue 
size  of  the  presenting  part.  In  the  latter  way  may  be  ex])laincd  the 
ol)servation  that  rupture  is  more  frequently  met  with  in  the  delivery  of 
male  than  of  female  children,  on  account,  no  doubt,  of  the  larger  size 
of  the  head  in  the  former.  The  influence  of  intra-uterine  hydroceph- 
alus was  first  prominently  pointed  out  by  Sir  James  Simpson,"  who  states 
that  out  of  74  cases  of  intra-uterine  hydrocephalus  the  uterus  ruptured 
in  16.  In  all  such  cases  of  disjirojjortion,  whether  referable  to  the  pel- 
vis or  foetus,  rupture  is  produced  in  a  twofold  manner — either  by  the 
excessive  and  fruitless  uterine  contractions  which  are  induced  by  the 
efforts  of  the  organ  to  overcome  the  obstacle,  or  by  the  compression  of 
the  uterine  tissue  between  the  presenting  part  and  the  bony  pelvis,  lead- 
ing to  inflammation,  softening,  and  even  gangrene. 

The  j^roximate  cause  of  rupture  may  be  classed  under  two  heads — 
(mechanical    injury)  and  /excessive    uterine    contraction.)      Under    the 
former  are   j)laced  those   nncommon   cases  in   which  the  uterus    lace- 
rates as  the  result  of  some  injury  in  the  latter  months  of  pregnancy, 
such  as  blows,  falls,  and  the  like.     Xot  so  mre,  unfortunately,  are  lace- 

'  Obst.  Trans.,  1867,  vol.  viii.  p.  150.  ^  Selected  Obstetric  Works,  p.  385. 


RUPTURE  OF  THE   UTERUS,  ETC. 


441 


rations  prodnood  l)v  unskilled  attempts  at  dellvciy  on  the  part  of  the 
iiiodical  attendant,  such  as  by  the  hand  dtn-ing  turning  or  by  the  l)lades 
of  the  forceps.  Many  such  cases  are  on  record  in  which  tiie  accoucheur 
has  used  force  and  violence,  rather  than  skill,  in  his  attempts  to  over- 
come an  obstacle.  That  such  unhappy  results  of  ignorance  are  not  so 
uncommon  as  they  ought  to  be  is  proved  by  the  figures  of  Jolly,  who 

Fig.  150. 


lUustrating  the  Dangerous  Thinning  of  the  Lower  Segment  of  Uterus,  owing  to  non-descent  of 
head  in  a  case  of  intra-uterine  hydrocephalus.    (After  Bandl.) 

has  collected  148  cases  of  rupture  of  the  uterus ;  of  which  71  occurred 
during  version  by  the  feet ;  37  under  the  use  of  the  forceps ;  10  under 
that  of  the  cephalotribe,  and  30  during  other  operations,  the  preci.se 
nature  of  which  is  not  stated.'  The  modus  operandi  of  protracted 
and  ineffectual  uterine  contractions  as  a  proximate  cause  of  rup- 
ture is  sufficiently  evident,  and  need  not  be  dwelt  on.  It  is  neces- 
sary to  allude,  however,  to  the  effect  of  ergot,  incautiously  adminis- 
tered, as  a  producing  cause.  There  is  al)undant  evidence  that  the 
injudicious  exhibition  of  this  drug  has  often  been  followed  by  lace- 
ration of  the  unduly  stimulated  uterine  fibres.  Thus,  Trask,  talking  of 
tlie  subject,  says  that  Meigs  had  seen  3  cases,  and  Bedford  4,  distinctly 
traceable  to  this  cause.  Jolly  found  that  ergot  had  been  administered 
largely  in  33  cases  in  which  rupture  occurred. 

Premonitory  Symptoms. — Some  have  believed  that  the  impending 
occurrence  of  rupture  could  frequently  be  ascertained  by  peculiar  pre- 

1  Op.  cii. 


442  LABOR. 

moil itorv  symptoms,  sucli  as  excessive  and  acute  erainpy  j)aiiis  about  the 
k)\ver  ])art  ol"  tlic  al)(loMii'U,  due  t(»  the  compression  (»f  j)ai-t  of  the  utei'ine 
wails.  Tliese  are  l"ar  too  indefinite  to  l)e  relied  on,  and  it  is  certain  that 
the  ru])ture  irenerally  takes  place  without  any  symptoms  that  would  have 
aflorded  reasonal)le  iirouuds  for  suspicion. 

The  general  symptoms  are  often  so  distinct  and  alarmiujs;  as  to  leave 
no  doubt  as  to  the  natmv  of  the  case.  Not  infre(juently,  however,  especi- 
ally if  the  lacei'ation  be  ])artial,  they  are  by  no  means  so  well  marked, 
and  the  j)ractitioner  may  be  imcertain  as  to  what  has  taken  place.  In  the 
former  class  of  cases  a  sudden  excruciatint;-  pain  is  experienced  in  the 
abdomen,  generally  during  the  uterine  contractions,  accompanied  by  a 
feeling  on  the  part  of  the  patient  of  something  having  given  way. 
In  some  cases  this  has  been  accompanied  by  an  audible  sound  which 
has  been  noticed  by  the  bystanders.  At  the  same  time,  there  is  gener- 
ally a  considerable  escaj)e  of  blood  from  the  vagina,  and  a  prominent 
symptom  is  the  sudden  cessation  of  the  previously  strong  ])ains. 
Alarming  general  symptoms  soon  develop,  ])artly  due  to  shock, 
partly  to  loss  of  blood,  both  external  and  internal.  The  face  ex- 
hibits the  greatest  suffering,  the  skin  becomes  deadly  cold  and  covere<l 
with  a  clammy  sweat,  and  fainting,  collapse,  rapid  feeble  pulse,  hnrried 
breathing,  vomiting,  and  all  the  usual  signs  of  extreme  exhanstion 
quickly  follow. 

Abdominal  palpation  and  vaginal  examination  both  afford  character- 
istic indications  in  well-marked  cases.  If  the  child,  as  often  ha})pens, 
lias  escaped  entirely  or  in  great  part  into  the  abdominal  cavity,  it  may 
be  readily  felt  through  the  abdominal  walls;  while  in  the  former  ca.se 
the  partially-contracted  uterus  may  be  found  separate  from  it  in  the 
form  of  a  globular  tumor  resembling  the  uterus  after  delivery.  JW 
vagjnam,  it  can  generally  be  ascertained  that  the  presenting  part  has  sud- 
denly receded  and  is  no  longer  to  be  made  out,  or  some  other  ])art  of  the 
foetus  is  found  in  its  place.  If  the  rupture  be  extensive,  it  may  be 
appreciable  on  vaginal  examination,  and  sometimes  a  loop  of  intestine 
will  be  found  ju'otrnding  through  the  tear.  Other  occasional  signs  have 
been  recorded,  such  as  an  emphysematous  state  of  the  lower  ]iart  of  the 
abdomen,  resulting  from  the  entrance  of  air  into  the  cellular  tissue  ov  the 
formation  of  a  sanguineous  tumor  in  the  hypogastrium  or  vagina.  These 
are  too  nncoramon  and  too  vague  to  be  of  much  diagnostic  value. 

Unfortunately,  the  symptoms  are  by  no  means  always  so  distinct,  and 
cases  occur  in  which  most  of  the  relial)le  indications,  such  as  the  sudden 
cessation  of  the  pains,  the  external  hemorrhage,  and  the  retrocession  of 
the  presenting  part,  may  be  absent.  In  some  cases,  indeed,  the  symp- 
toms have  l)een  so  obscure  that  the  real  nattu'c  of  the  case  has  oidy 
been  detected  after  death.  It  is  rarely,  however,  that  the  occurrence 
of  shock  and  prostration  is  not  sufficiently  distinct  to  arouse  susj)icion, 
even  in  the  absence  of  the  nsual  marked  signs.  In  not  a  few  cases  dis- 
tinct and  regidar  contractions  have  gone  on  after  laceration,  and  the 
child  has  even  been  born  in  the  nsual  way.  Of  course  in  such  a  case 
mistake  is  very  possible.  So  curious  a  circumstance  is  difffcult  of  exjda- 
nation.  The  most  probable  way  of  accoiuiting  for  it  is,  that  the  lacera- 
tion has  not  implicated  the  fundus  of  the  nterus,  which  contracted  suf- 


RUPTURE  OF  TIIK   UTERUS,   ETC.  443 

fleiciitly  energetically  to  expel  the  fu'tus.  Hence  it  will  be  seen  that 
the  syniptonis  are  occasionally  obscure,  and  the  practitioner  must  be 
careful  not  to  overlook  the  occurrence  of  so  serious  an  accident  because 
of  the  absence  of  the  usual  and  characteristic  symptoms. 

The  prognosis  is  necessarily  of  the  gravest^jif)ssible  character,  but 
modern  views  as  to  treatment  j)erhai)S  justify  us  in  saying  that  it  is  not 
so  absolutely  hoi)eless  as  has  been  generally  taught  in  our  ol)stetric 
works.  When  we  reflect  on  Avhat  has  occurred — the  profound  nervous 
shock ;  the  profuse  hemorrhage,  both  external,  and,  especially,  into  the 
peritoneal  cavity,  where  the  blood  coagulates  and  forms  a  foreign  body; 
the  passage  of  the  uterine  contents  into  the  abdomen,  with  the  inevita- 
ble result  of  inflammation  and  its  consequences  if  the  patient  survive 
the  primary  shock, — the  enormous  fatality  need  cause  no  surprise.  Jolly 
has  found  that  out  of  580  cases  100  recovered ;  that  is,  in  the  propor- 
tion of  1  out  of  6.  This  is  a  far  more  favorable  result  than  we  are 
generally  led  to  antici})ate ;  and  as  many  of  the  recoveries  happened  in 
apparently  the  most  desperate  and  unfavorable  cases,  we  should  learn 
the  lesson  that  we  need  not  abandon  all  hope,  and  should  at  least 
endeavor  to  rescue  the  patient  from  the  terrible  dangers  to  which  she 
is  exposed. 

As  regards  the  child,  the  pi-ognosis  is  almost  necessarily  fatal ;  and, 
indeed,  the  cessation  of  the  foetal  heart-sounds  has  been  pointed  out  by 
McClintock  as  a  sign  of  rupture  in  doubtful  cases.  The  shock,  the 
profuse  hemorrhage,  and  the  time  that  must  necessarily  elapse  before 
the  delivery  of  the  child  are  of  themselves  qnite  sufficient  to  explain 
the  fact  that  the  foetus  is  almost  always  dead. 

Treatment. — From  what  has  been  said  of  the  impossibility  of  fore- 
telling the  occurrence  of  rupture,  it  must  follow  that  no  reliable  pro- 
phylactic treatment  can  be  adoj^ted  beyond  that  which  is  a  matter  of 
general  obstetric  principle — viz.  timely  interference  when  the  nterine 
contractions  seem  incapable  of  overcoming  an  obstacle  to  delivery, 
either  on  the  part  of  the  pelvis  or  foetus. 

After  rupture  the  main  indications  are  to  effect  the  removal  of  the 
child  and  the  placenta,  to  rally  the  patient  from  the  effects  of  the  shock, 
and,  if  she  survives  so  long,  to  combat  the  subsequent  inflammation  and 
its  consequences.  By  far  the  most  important  point  to  decide  is  the  best 
means  to  be  adopted  for  the  removal  of  the  child,  for  it  is  admitted  by 
all  that  the  hopeless  expectancy  that  was  recommended  by  the  older 
accoucheurs — or,  in  other  words,  allowing  the  patient  to  die  without 
making  any  effort  to  save  her — is  quite  inadmissible.  If  the  foetus  be 
entirely  within  the  uterine  cavity,  no  doubt  the  proper  course  to  pursue 
is  to  deliver  at  once  per  vias  naturaks,  either  by  turning,  by  forcei^s,  or 
by  cephalotripsy.  If  any  part  other  than  the  head  present,  turning 
"svill  be  best,  great  care  being  taken  to  avoid  further  increase  of  the  lace- 
ration. If  the  head  be  in  the  cavity  or  at  the  brim  of  the  pelvis  and 
within  easy  reach  of  the  foi'ceps,  it  may  be  cautiously  apjilied,  the  cliild 
being  steadied  by  abdominal  pressure  so  as  to  facilitate  its  application. 
If  there  be,  as  is  often  the  case,  some  slight  amount  of  pelvic  contrac- 
tion, it  may  be  preferable  to  perforate  and  apply  the  cephalotribe.  so 
as  to  avoid  any  forcible  attempts  at  extraction  which   might  unduly 


444  LABOR 

o.xliaust  the  already  j)n)strate  patient  and  turn  tlie  scale  against  lier. 
This  will  he  the  more  all<)\val)le  sinee  the  c-hild  is,  as  we  have  seen, 
almost  always  dead,  and  we  mii^ht  readily  ascertain  ii'  it  be  so  l)y 
auscultation. 

(After  delivery  extreme  care  must  be  taken  in  removing  the  placenta, 
and  for  this  it  will  be  necessary  to  introduce  the  hand;  The  ])lacenta 
Avill  <«;enerally  be  in  the  uterus,  for  if  the  rent  be  not  large  enough  for 
the  child  to  ])ass  througli,  it  may  be  inferred  that  the  })lacenta  will  not 
liavc  done  so  either.  If  it  has  escaped  from  the  uterus,  very  gentle 
traction  on  the  cord  may  bring  it  within  reach  of  the  hand,  and  so 
the  passage  of  the  hand  through  the  tear  to  search  for  it  will  be 
avoided. 

There  can  be  hut  little  doubt  that  in  the  cases  indicated  such  is  the 
proper  treatment  and  that  which  affords  the  mother  the  best  chance. 
Unfortunately,  the  cases  in  which  the  child  remains  entirely  in  utcro 
are  comparatively  uncommon,  and  generally  it  will  have  escaped  into 
the  abdomen,  along  w'ith  much  extravasated  blood.  The  usual  plan  of 
treatment  recommended  under  such  circumstances  is  to  pass  the  hand 
through  the  fissure  (some  have  even  recommended  that  it  should  be 
enlarged  by  incision  if  necessary),  to  seize  the  feet  of  the  foetus,  to  drag 
it  back  through  the  torn  uterus,  and  then  to  reintroduce  the  hand  to 
search  for  and  remove  the  placenta.  Imagine  what  occurs  during  the 
process.  The  hand  groi:)es  blindly  among  the  abdominal  viscera,  the 
forcible  dragging  back  of  the  foetus  necessarily  tears  the  uterus  more 
and  more,  and,  above  all,  the  extravasated  blood  remains  as  a  foreign 
body  in  the  j^critoneal  cavity,  and  necessarily  gives  rise  to  the  most 
serious  consequences.  (It  is  surely  hardly  a  matter  of  surprise  that 
there  is  scarcely  a  single  case  on  record  of  recovery  after  this  })ro- 
cedure.) 

Of  Tate  years  a  strong  feeling  has  existed  that  whenever  the  child 
has  entirely  or  in  great  })art  escaped  into  the  abdominal  cavity  the  ope- 
ration of  gastrotomy  affords  the  mother  a  far  better  chance  of  recovery  ; 
and  it  has  now  been  performed  in  many  cases  with  the  most  encourag- 
ing results.  It  is  easy  to  see  why  the  prosjiects  of  success  are  greater. 
The  uterus  being  already  torn  and  the  jieritoneum  opened,  the  only 
additional  danger  is  the  incision  of  the  abdominal  parietes,  which  gives 
us  the  opi)ortunity  of  sponging  out  the  ])eritoneal  cavity  as  in  ovariot- 
omy, and  of  removing  all  the  extravasated  blood,  the  retention  of  which 
so  seriously  adds  to  the  dangers  of  the  case.  Another  advantage  is 
that  if  the  patient  be  excessively  prostrate  the  operation  may  be  delayetl 
until  she  has  somewhat  rallied  from  the  effects  of  the  shock,  whereas 
delivery  by  the  feet  is  generally  resorted  to  as  soon  as  the  rui)ture  is 
recognized,  and  when  the  patient  is  in  the  worst  possible  condition  for 
interference  of  any  kind. 

Jolly  has  carei'ully  tabulated  the  results  of  the  various  methods  of 
treatment,  and,  making  every  allowance  for  the  unavoidable  errors  of 
statistics,  it  seems  beyond  all  question  that  the  results  of  gastrotomy  are 
so  greatly  superior  to  those  of  other  plans  that  I  think  its  adoj^tion  may 
fairly  be  laid  down  as  a  rule  whenever  the  foetus  is  no  longer  within  the 
uterine  cavity : 


RUPTURE  OF  THE   UTERUS,  ETC. 


445 


COMPARATIVK   RfSITLT.S   OF   VARIOUS   METHODS   OF   TREATMENT   AFTER 

Rupture  of  Uterus. 


Treatment. 


Expectation 

Extraction  per  vias  naturales 
Gastrotomy 


No,  of 
Cases. 


144 
382 

38 


Deaths. 


142 

310 

12 


Recoveries, 


2 
72 
26 


Per  cent,  of 
Recoveries. 


1.45 
19 
68.4 


Of  course  tliis  table  will  not  justify  the  conclusion  that  68  per  cent, 
of  the  cases  of  ruptured  uterus  in  which  gastrotomy  is  performed  will 
recover,  but  it  may  fairly  be  taken  as  proving  that  the  chances  of  recov- 
ery are  at  least  three  or  four  times  as  great  as  when  the  more  usual  prac- 
tice is  adopted.^ 

Porro's  operation  has  been  suggested  instead  of  simple  gastrotomy. 
In  seven. cases  tabulated  by  Godson,  in  which  this  operation  w'as  per- 
formed after  rupture  of  the  uterus,  the  mothers  all  died  ;^  but  this 
does  not  prove  that  this  plan,  which  adds  little  to  the  dangers  of  the 
case,  should  not  be  adopted.  It  has,  at  least,  the  advantage  of  effect- 
ually preventing  the  possibility  of  the  recurrence  of  rupture  in  a  future 
pregnancy. 

[Supravaginal  hysterectomy,  unless  preceded  by  a  true  Cesarean  sec- 
tion, has  no  right  or  title  to  the  name  of  "  Porro,"  any  more  than  the 
same  operation  for  a  uterine  fibroma  has.  If  it  is  to  bear  the  name  of 
any  man,  it  should  be  that  of  Prevot,  who  introduced  it  at  Mosco\v^  on 
Nov.  22,  1878.  The  method  has  two  very  serious  objections  to  its 
performance :  1,  it  is  generally  fatal  in  its  results;  2,  we  have  no  right 
to  unsex  a  Avell-formed  woman  because  she  has  had  the  misfortune  to 
rupture  her  uterus,  when  a  better  result  may  be  attained  by  carefully 
suturing  the  laceration. — Ed.] 

Lacerations  of  the  cervix  are  of  very  common  occurrence.  Occa- 
sionally, after  delivery,  they  may  cause  hemorrhage  when  the  uterus 
itself  is  firmly  contracted  or  secondary  hemorrhage  during  the  puerperal 
month.  As  a  rule,  they  are  not  recognized,  and  it  is  only  of  late  years, 
chiefly  owing  to  the  labors  of  Emmet,  that  their  important  influence  in 
producing  various  chronic  forms  of  uterine  disease  has  been  realized. 
In  the  large  majority  of  cases  the  lacerations  are  lateral,  either  on  one 
or  both  sides  of  the  cervix.  If  they  give  rise  to  hemorrhages,  the  local 
application  of  styptics  is  probably  the  best  resource.     Whether  it  is 

'American  Puerperal  Laparotomies. — After  a  search  of  several  years  I 
have  thus  far  collected  43  cases  in  the  United  States,  with  21  women  and  2  children 
saved.  One  mother  and  child  were  saved  by  an  immediate  operation  with  a  pocket- 
knife  in  1869.  I  presume  that  a  general  record  of  American  operations  i)ul)lished 
and  unpublished  would  siiow  a  saving  of  about  50  per  cent.,  which  is  nuich  lower  than 
tliat  claimed  by  Trask  and  Jolly,  collected  from  published  reports,  and  less  than  I 
thought  myself  a  year  ago.  Take  Trask's  foreign  cases,  20,  and  our  own  43,  and  we 
have,  native  and  foreign,  63,  with  37  recoveries  and  26  deaths.  I  look  upon  our  own 
statistics  as  mucli  more  reliable,  because  many  of  tiie  mipulilished  cases  were  searched 
out  by  corresjiondence. — Harris'  note  to  fourth  American  edition. 

^  A  successful  case  has  recently  been  reported  by  Professor  Slavjansky  of  St.  Peters- 
burar. 


446  LMlOR. 

ailvisal)le  to  treat  severe  forms  hy  tlie  innuediatc  apj)lieati(»ii  of  silvei 
sutures,  as  reeoniineniled  hy  Palleii,'  is  a  sul)jeet  as  yet  too  little  under- 
stood to  justiiy  the  expression  of  an  oi)inion. 

It  is  perhaps  needless  to  say  that  the  0j)eratiou  must  be  ])erl"ormed 
Avith  the  same  minute  eare  that  has  raised  ovariotomy  to  its  present  pitch 
of  perfection,  and  that  esjx'cial  attention  should  l)o  ])aid  to  tlie  spongint!; 
out  of  the  peritoneum  and  the  removal  of  foreign  matters. 

Recapitulation. — To  recapitulate,  I  think  what  has  been  said  justi- 
fies the  following  rules  of  treatment  after  ru})ture : 

1.  If  the  head  or  presenting  part  be  above  the  brim  and  the  fietus 
still  in  ukro — forceps,  turning,  or  cephalotripsy  according  to  circum- 
stances. 

2.  If  the  head  be  in  the  pelvic  cavity — force])s  or  cephalotripsy. 

3.  If  the  feetus  have  wholly  or  in  great  part  escaped  into  the  abdom- 
inal cavity — gastrotoray. 

As  to  the  subsequent  treatment,  little  need  be  said,  since  in  this  we 
must  be  guided  by  general  principles.  The  chief  indication  will  be  to 
remove  shock  and  rally  the  patient  by  stimulants,  etc.,  and  to  combat 
secondary  results  by  opiates  and  other  ap])ropriate  remedies. 

Drainaije  has  been  recommended  in  cases  in  which  o:astrotom\'  has  not 
been  resorted  to,  and  the  results  are  said  to  have  been  good.  Mann^ 
advises  that  a  large  piece  of  drainage-tube  should  be  l)ent  in  the  middle, 
at  which  point  a  free  opening  should  be  made.  This  bent  portion  is 
passed  for  about  half  an  inch  through  the  laceration ;  the  free  ends  are 
fastened  together  beyond  the  vulva  and  covered  with  an  antisejitic 
dressing.  After  forty-eight  hours  the  wound  should  be  regularly  irri- 
gated with  2  per  cent,  solution  of  carbolic  acid. 

Lacerations  of  the  vagina  occasionally  take  place,  and  in  the  great 
majority  of  cases  they  are  produced  by  instruments,  either  from  a  want 
of  care  in  their  introduction  or  from  undue  stretching  of  the  vaginal 
walls  during  extraction  with  the  forceps.  Slight  vaginal  lacerations 
are  probably  much  more  common  after  forceps  delivery  than  is  generally 
believed  to  be  the  case.  As  a  rule,  they  are  productive  of  no  permanent 
injury,  although  it  must  not  be  forgotten  that  every  breach  of  continuity 
increases  the  risk  of  subsequent  septic  absorption.  When  the  laceration 
is  sufficiently  deep  to  tear  through  the  recto-vaginal  septum  or  the 
anterior  vaginal  wall,  the  passage  of  the  urine  or  feces  is  apt  to  jirevent 
its  edges  uniting;  then  that  most  distressing  condition,  recto-vaginal  or 
vesico-vaginal  fistula,  is  established. 

It  nuist  not  be  supposed  that  fistnlte  are  often  the  result  of  injury 
during  operative  interference.  That  is  a  common  but  very  erroneous 
opinion  both  among  the  profession  and  the  public.  In  the  vast  majority 
of  cases  the  fistulous  opening  is  the  consequence  of  a  slough  resulting 
from  inflammation,  ])roduced  by  long-continued  pressure  of  the  vaginal 
M-alls  between  the  child's  head  and  the  bony  pelvis  in  cases  in  which 
the  second  stage  has  been  allowed  to  go  on  too  long.  In  most  of  the.se 
cases  instruments  were  doubtless  eventually  used,  and  they  got  the  blame 
of  the  accident ;  whereas  the  fault  lay,  not  in  their  being  employed,  but 

^  Transact ioii.-i  nf  ike  lulcn}.  Med.  Co7}gr.,  vol.  iv. 
»  CcntralblaUf.'GynaL,  Bd.  v.  S.,  37l 


RUPTriiK  OF  THE   UTERUS,   ETC.  447 

ratlier  iu  their  not  liaviiig  been  used  soon  enon<^h  to  prevent  tlie  con- 
tusion and  iiiHaiHination  whieli  ended  iu  slout^liing. 

When  vesico-vaginal  fistulte  are  the  resuU  of"  hieerations  durinjr  hihor, 
the  urine  must  escape  at  once;  but  this  is  rarely  the  case.  In  tlie  ku'ge 
niajoritv  ol"  cases  the  urine  does  not  pass  per  varj'inaiii  until  more  tlian  a 
week  after  delivery,  showing  that  a  lapse  of  time  is  necessary  for  inflam- 
matory action  to  lead  to  sloughing.  In  order  to  throw  some  light  on 
these  ])oints,  on  which  very  erroneous  views  have  been  held,  I  have 
<'arefully  examined  the  histories,  from  various  sources,  of  63  cases  of 
vesieo- vaginal  tislula  : 

Statistical  Facts. — 1st,  Iu  20  no  instruments  were  employed.  Of 
these  there  were  in  labor 

Under  24  hours 2 

From  24  to  48      "      8 ' 

40  to  70      "      2 

70  to  80      "      7 

80  hours  and  upward 1 

20 

Therefore,  out  of  these  20  cases  one-half  were  certainly  more  than 
forty-eight  hours  in  labor,  and  6  of  the  remaining  10  were  probably  so 
idso.  In  only  1  of  them  is  the  urine  stated  to  have  escaped  per  vaginam 
immediately  after  delivery.  In  7  it  is  said  to  have  done  so  within  a 
week,  and  in  the  remainder  after  the  seventh  day. 

2d,  In  34  cases  instruments  were  used,  but  there  is  no  evidence  of 
their  having  produced  the  accident.     Of  these  there  were  iu  labor 

Under  24  hours 2 

From  24  to  48      "      8 

48  to  72      "      10 

72  liours  and  upward 14 

34 

The  urine  escajDed  within  twenty-four  hours  in  2  cases  only,  within  a 
week  in  16,  and  after  the  seventh  day  in  15, 

So  that  here,  again,  we  have  the  history  of  unduly  protracted  delivery, 
24  out  of  the  34  having  been  certainly  more  than  forty-eight  hours  in 
labor, 

3d.  In  9  cases  the  histories  show  that  the  production  of  the  fistula 
may  fairly  be  ascribed  to  the  unskilled  use  of  instruments.  Of  these 
there  were  in  labor 

Under  24  hours 7 

From  24  to  48      "      1 

48  to  72      "      1 

9 

The  urine  escaped  at  once  in  7  cases,  and  in  the  remaining  2  after  the 
seventh  day. 

These  statistics  seem  to  me  to  prove  in  the  clearest  manner  that  in 
the  large  majority  of  cases  this  unhappy  accident  may  be  directly  traced 
to  the  bad  practice  of  allowing  labor  to  drag  so  many  hours  iu  the 
second  stage  without  assistance,  and  not  to  premature  instrumental  inter- 

'  But  of  these  in  7  no  precise  time  is  stated;  6  of  them  are  marked  very  tedious; 
therefore  they  probably  exceeded  tlie  limit. 


448  LABOR. 

fcreiice.  This  question  lias  recently  bcoii  clalxtratcly  studied  In  Eniinet, 
who  pves  numerous  statistical  tables  which  fully  c<»iTolj<»rate  these  views. 
His  conclusion,  the  result  oi'  nuich  j)ractical  experience  ot"  vesieo-va|rinal 
Hstuhe,  is  worthy  of"  l)ein>;-  (juoted.  "  I  do  not  hesitate,"  lie  says,  "to 
niaUe  the  statement  that  J  have  never  met  with  a  case  of  vesico-va<:inal 
fistula  which,  without  doubt,  could  be  shown  to  have  resulted  from 
instrumental  delivery.  On  the  contrary,  the  entire  weight  of  evidence 
is  conclusive  in  showino;  that  the  injury  is  a  consequence  of  delav  in 
delivery.'" 

Treatment. — As  to  the  treatment  of  va.<i:inal  iacci-ation,  little  can  be 
said.  In  the  slighter  cases  vaginal  injections  of  diluted  Condy's  fluid 
will  be  useful  to  lessen  the  risk  of  se})tic  absorjition,  and  the  graver, 
when  vesico-vaginal  or  recto-vaginal  fistuke  have  actually  formed,  are 
not  within  the  domain  of  the  obstetrician,  but  must  be  treated  surgically 
at  some  future  date. 

[The  Rational  Treatment  of  Rupture  of  the  Uterus. — The  three 
rules  given  on  page  446  are  those  found  in  ol:)stctrical  wtjrks  of  high 
authority,  but  are  not  based  upon  the  teachings  of  abdominal  surgery  as 
shown  by  the  results  of  operations  recorded  within  a  few  years.  Reason- 
ing from  analogy  and  the  fearful  mortality  of  cases  delivered  per  vicc^ 
iiafuralcs  after  uterine  rupture,  we  are  forced  to  the  conclusion  that 
something  more  is  needed  than  the  delivery  of  the  woman  and  the 
removal  of  the  placenta  if  we  hope  to  reduce  the  proportion  of  deaths, 
which  is  very  great  except  after  laparotomy — a  method  of  delivery 
capable  of  saving  nearly  50  per  cent.  There  is  no  objection  to  delivering 
the  foetus  by  the  natural  channel,  provided  it  can  be  readily  done;  but 
we  have  very  little  reason  to  anticipate  a  favoral)le  result  if  ^\•e  rest  our 
efforts  here.  Children  entirely  escaped  into  the  alxlominal  cavity  have 
been  drawn  back  through  the  rent  and  delivered  by  the  vagina,  and  the 
women  have  recovered.  In  one  well-authenticated  case  the  woman  was 
thus  saved  in  our  own  country  on  four  occasions.  But  we  are  not  to 
ex])cct  such  results,  as  a  fatal  issue  is  far  more  frequent  than  a  recoveiy 
under  such  circumstances.  Our  object  should  be  to  save  the  life  of  the 
mother  and,  if  at  all  possible,  that  of  the  fa?tus,  and  all  our  eflorts 
should  be  directed  to  this  end.  AVe  may  console  ourselves  with  having 
delivered  the  woman  prior  to  her  death,  but  to  prevent  this  fatal  issue 
should  be  our  chief  aim.  The  general  impression  among  ovariotomists 
is,  that  blood  is  not  an  innocent  fluid  in  the  abdominal  cavity  ;  and  the 
remarkable  results  of  the  operations  of  Dr.  Keith  of  l^iondon,  formerly  of 
Edinburgh,  are  attributed  to  the  care  he  exercises  in  jirevcnting  the  second- 
ary escape  of  blood  into  the  abdominal  cavity.  Dr.  Ludwig  Winekt'l  of 
Mullheim,  Germany,  who  performed  the  Coosarean  operation  13  times  and 
laparotomy  after  rupture  of  the  uterus  4  times,  was  of  the  impression  that 
the  liquor  amnii  Avas  innocuous  if  oidy  a  short  time  in  contact  with  the 
peritonemn  ;  and  the  same  may  l)e  said  of  blood,  ovarian  fluid,  jiarova- 
rian  fluid,  and,  to  some  degree,  also  of  urine.  I\u])ture  of  the  bladder 
is  now  cured  by  sewing  up  the  rent  and  carefully  cleansing  the  abdom- 
inal cavity  of  blood  and  urine.  But  these  fluids  are  all  capable  of 
setting  up  peritonitis,  and  blood  by  its  decomposition  is  particularly  ai)t 

'  The  Piinciples  and  Practice  of  Gyncscology,  p.  669. 


INVERSION  OF  THE    UTERUS.  449 

to  give  rise  to  septic  poisoning  :  then  why  let  it  remain  in  the  abdominal 
cavity  in  cases  of  ruptured  uterus?  If  it  is  important  to  cleanse  this 
cavity  from  blood  and  ovarian  fluid  in  ovariotomy,  and  from  blood  and 
amniotic  fluid  after  the  Csesarean  section,  then  why  should  we  be  content 
M'ith  delivering  the  fcotus  in  cases  of  rupture  of  tiie  uterus,  when  we 
know  that  the  peritoneal  cavity  still  contains  a  compound  fluid  which 
may  tlestroy  the  woman  if  not  removed  and  the  parts  cleansed  ?  We 
have  also  an  additional  risk  in  the  fact  that  the  uterine  rupture  may 
gape  and  allow  the  lochia  to  escaj)e  into  the  peritoneal  cavity,  thus  pro- 
viding another  element  for  septic  poisoning.  V I  am,  then,  fully  per- 
suaded that  in  all  cases  of  rupture,  where  it  is  evident  that  blood 
and  liquor  amnii  have  escaped  into  the  abdominal  cavity,  we  ought 
to  open  the  abdomen,  cleanse  out  the  cavity,  and  close  up  the  rent  by 
deejvseated  and  superficial  sutures  of  carbolized  pure  silk.  In  cervico- 
vaginal  rupture  the  closure  of  the  rent  may  not  be  so  important  in  the 
sense  of  safety  to  the  woman,  as  there  is  generally  a  natural  drainage 
into  the  vagina ;  neither  is  laparotomy  itself  so  iinperatively  demanded 
as  in  cases  where  the  fundus  or  body  of  the  uterus  is  rent.  But  it 
becomes  important  to  close  the  rent  cervix  in  view  of  future  trouble 
from  ectropium  and  erosion.  As  in  the  Csesarean  operation,  promptness 
of  action  is  all  important  if  we  hope  to  save  the  patient.  I  know  that 
these  views  upon  the  treatment  of  ruptured  uterus  are  in  advance  of 
those  held  by  British  obstetrical  writers,  but  they  are  certainly  logical 
deductions  from  the  experience  of  such  operators  as  Dr.  Keith,  jNIr. 
Lawson  Tait,  and  others,  and  from  the  well-known  results  of  promptly- 
performed  laparotomies  in  rupture  accidents  in  the  United  States.  The 
removal  of  the  uterus  after  rupture  has  as  yet  only  added  to  the  risk, 
and  I  do  not  believe  we  are  justified  in  resorting  to  it  where  there  is  no 
pelvic  obstruction. — Ed.] 


.      CHAPTER  XVII. 

INVERSION  OF  THE   UTERUS. 

Inversion  of  the  uterus  shortly  after  the  birth  of  iho^  child  is 
one  of  the  most  forjuidable  accidents  of  parturition,  leading  to  svmp- 
toms  of  the  greatest  urgency^  not  rarely  proving  fatal^  and  requiring 
prom])t  and  skilful  treatment.  Hence  it  has  attained  an  unusual 
amount  of  attention,  and  there  are  few  obstetric  subjects  which  have 
been  more  carefully  studied. 

Fortunately,  the  accident  is  of_great._rarit)'.  It  was  onlv  observed 
once  in  ujnvard  of  190,800  deliveries  at  the  Rotunda  Hospital  since 
its  foundation  in   1745,  and  many  practitioners  have  conducted  large 

29 


450 


LABOR. 


Fig.  151. 


miflwifcrv  pi-Mcticos  for  a  lifotinic  witli(jut  cvor  liaviii*;  witncssod  n  f-ase. 
]t  is  iKtiic  (he  loss  iict'df'ul,  liowcver,  that  ^ve  slntuld  ho  tlionjiitrlily 
acqiiaintod  with  its  natural  histor}'  and  with  tlio  host  moans  of  dealing 
Avith  tho  cniorjjonoy  when   it  arises. 

Acute  and  Chronic  Forms. — Inversion  of  tlio  uterus  may  l^*-  met 
with  in  tho  aouto  or  ohronie  form  ;  that  is  to  say,  it  may  come  under 
observation  either  immediately  or  shortly  after  its  occurrence,  or  not 
until  after  a  considei'ahlo  ]aj)so  of  time  when  the  involution  foilowinii; 
pregnancy  has  been  completed.  The  latter  falls  more  properly  under 
the  province  of  the  gynecologist,  and  involves  the  consideration  of 
many  points  that  would  be  out  of  place  in  a  work  on  obstetrics.  Here, 
therefore,  the  acute  form  alone  is  considered. 

Description. — Inversion  consists  essentially  in  the  enlarged  and 
empty  uterus  being  turned  inside  out,  either  ])artially  or  entirely  ;  and 
this  may  occur  in  various  degrees,  three  of  which  are  usually  descrii)ed 
and  are  practically  useful  to  bear  in  mind.  In  the  fir.st  and  slightest 
degree  there  is  merely  a  cup-shaped  depression  of  the  fundus  (Fig. 
151);  in  the  second  the  depression  is  greater,  so  that  the  inverted  por- 
tion forms  an  inti'osusception,  as  it  were,  and  prf»jects  downward  through 

the  OS  in  the  form  of  a  round  ball,  not  un- 
like the  body  of  a  polypus,  for  which,  in- 
deed, a  careless  observer  might  mistake  it ; 
and,  thirdly,  there  is  the  complete  variety,  in 
which  the  whole  organ  is  turned  inside  out, 
and  may  oven  ])n)ject  beyond  the  vulva. 

The  symptoms  are  generally  very  cha- 
racteristic, although,  when  the  amount  of 
inversion  is  small,  they  may  entirely  escape 
ol)servation.  They  arc  chiefly  those  of  ])ro- 
found  nervous  shock — viz.,  fainting,  small, 
rapid,  and  feeble  ])ulse,  possibly  convulsions 
and  vomiting,  and  a  cold,  clammy  skin. 
Occasionally  severe  abdominal  })ain  and 
bearing  down  are  felt.  Hemorrhage  is  a 
frequent  accompaniment,  .somotnnes  to  a 
very  alarming  extent,  especially  if  the 
]>laconta  be  ])artially  or  entirely  detached. 
Tho  loss  of  blood  depends  to  a  groat  extent 
on  the  condition  of  the  uterine  parietes.  If 
there  be  much  contraction  on  the  part  that 
is  not  inverted,  the  introsusce]>tcd  part  may 
be  .suifieiently  compressed  t(t  jirovent  any 
groat  loss.  If  the  entire  organ  bo  in  a  state  of  rolax;ition,  the  loss  may 
be  excessive. 

The  occurrence  of  such  symptoms  shortly  alter  delivery  would  of 
necessity  lead  to  an  accurate  examination,  when  the  nature  of  the  case 
may  be  at  once  a.scertained.  On  pa.ssing  the  finger  into  the  vagina  we 
either  find  the  entire  uterus  forming  a  globular  ma.ss — to  which  the 
placenta  is  often  attached — or,  if  the  invasion  be  incomplete,  tho  vagina 
is  occupied  by  a  firm,  round,  and  tender  swelling,  Avhich  can  be  traced 


Partial  Inversion  of  the  Fundus. 

(From  a  pn-parsition  in  tlie  Museum  of 
Guy's  Hospital.) 


INVERSION  OF  THE   UTERUS.  451 

upward  tlir(ni<i;h  the  os  uteri.  The  hand  placed  oii  tlic  abdomen  will 
detect  (he  absence  of  the  round  ball  of"  the  contracted  uterus;  the 
bimanual  examination  may  eveu  enable  us  to  feel  the  cup-shaped 
de])ressi()n  at  the  site  of  inversion. 

Differential  Diagnosis. — When  such  signs  are  observed  immediately 
after  delivery  mistake  is  hardly  possible.  Numerous  instances,  how- 
ever, are  recorded  in  which  the  existence  of  inversion  was  not  imme- 
diately detected,  and  the  tumor  formed  by  it  only  observed  after  the 
laj)se  of  several  days,  or  even  longer,  when  the  general  symptoms  led  to 
vaginal  examination.  It  is  probable  that  in  such  cases  a  })artial  inver- 
sion had  taken  place  shortly  after  delivery,  which  as  time  elapsed  became 
gradually  converted  into  the  more  complete  variety.  In  a  case  of  this 
kind,  as  in  a  chronic  inversion,  some  care  is  necessary  to  distinguish  the 
inversion  from  a  uterine  polypus,  which  it  closely  resembles.  The 
cautious  insertion  of _the  so(iiiud  will  render  the  diagnosis  certain,  since 
its  passage  is  soon  arrested  in  inversion,  while  if  the  tumor  be  polypoid 
it  readily  passes  in  as  far  as  the  fundus. 

The  mechanism  by  -which  inversion  is  produced  is  well  worthy 
of  study,  and  has  given  rise  to  much  difference  of  opinion. 

A  very  general  theory  is  that  it  is  caused  in  many  cases  by(]nis- 
management  of  the  third  stage  of  laboi*)  either  by  traction  on  the  cord, 
the  placenta  being  still  adherent,  or  by  miprojperly  a})plied  pressure  on 
the  fundus,  the  result  of  both  these  errors  being  a  cup-shaped  depres- 
sion of  the  fundus  which  is  subsequently  converted  into  a  more  complete 
variety  of  inversion.  That  such  causes  may  suffice  to  start  the  inversion 
cannot  be  doubted,  but  it  is  probable  that  their  frequency  has  been  much 
exaggerated.  Still,  there  are  numerous  recorded  cases  in  which  the 
commencement  of  the  inversion  can  be  traced  to  them.  Improperly 
applied  pressure  (as  when  the  whole  body  of  the  uterus  is  not  grasped 
in  the  hollow  of  the  hand,  but  when  a  monthly  nurse  or  other  unin- 
structed  ])erson  presses  on  the  lower  part  of  the  abdomen,  so  as  simply 
to  push  down  the  uterus  en  masse)  is  often  mentioned  in  histories  of  the 
accident.  Thus,  in  the  Edinburgh  Medical  Jourmd  for  June,  1848,  a 
case  is  related  in  which  the  patient  would  not  have  a  medical  man,  but 
was  attended  by  a  midwife,  who  after  the  birth  of  the  child  ])ulled  on 
the  cord,  while  the  patient  herself  clasped  her  hands  and  pushed  down 
her  abdomen,  at  the  same  time  straining  forcibly,  when  the  uterus  became 
inverted  and  the  patient  died  of  hemorrhage  before  assistance  could  be 
procured.  Here  both  of  the  mechanical  causes  alluded  to  were  in  opera- 
tion. In  several  cases  it  is  mentioned  that  the  accident  occurred  while 
the  nurse  was  compressing  the  abdomen.  That  the  accident  is  practically 
im])ossible  when  firm  and  equable  contraction  has  taken  ])lace  cannot  be 
questioned.  Hence  it  is  of  paramount  importance  that  the  practitioner! 
should  himself  carefully  attend  to  the  conduct  of  the  third-  stage  of  • 
labor. 

In  a  large  j^i'oportion  of  cases  no  mechanical  causes  can  be  traced, 
and  the  occurrence  of  spontaneous  inversion  must  be  admitted.  There 
are  various  theories  held  as  to  how  this  occurs.  /  Partial  and  irregular 
contraction  of  the  uterus  is  generally  admitted  to  be  an  important  factor 
in  its  production  ;  but  it  is  still  a  matter  of  dispute  )whcther  the  iuver- 


452 


LABOR. 


sioii  is/pnxlueeil  mainly  l»y  an  active  contraction  of  the  fnndns  and 
body  oN  the  uterus,  the  h)\\er  portion  and  cervix  being  in  a  state  ot" 
rehixationAor  wlietiier  the  precise  reverse  ot"  this  exists/ the  f'unchis 
being  rehixed  and  in  a  state  of  (juasi-paralysis,  while  the  cervix  and 
lower  portion  of  the  uterus  are  irregularly  contracte(^  The  former  is 
the  view  maintained  by  Radford  and  Tyler  Smith,  while  the  latter  is 
upheld  by  Matthews  Duncan. 

There  are  good  clinical  reasons  for  believing  that  Duncan's  view 
more  nearly  corresponds  with  the  true  facts  of  the  case ;  for  if  the 
fundus  and  body  of  the  uterus  be  really  in  a  state  of  active  contrac- 
tion while  the  cervix  is  relaxed,  we  have,  as  Duncan  points  out,  the 
very  condition  which  is  normal  and  desirable  after  delivery,  and  that 
which  we  do  our  best  to  produce.  If,  however,  the  opposite  condition 
exist  and  the  fundus  be  relaxed,  while  the  loAver  portion  is  spasmodic- 
ally contracted,  a  state  exists  closely  allied  to  the  so-called  hour-glass 
contraction.  8ui)posing  now  any  cause  produces  a  partial  de})re.ssion 
of  the  fundus,  it  is  easy  to  understand  how  it  may  be  grasped  by  the 
contracted  portion  and  carried  more  and  more  down,  in  the  manner  of 
an  introsusception,  until  complete  inversion  results.  That  such  ])artial 
paralysis  of  the  uterine  walls  often  exists,  especially  about  the  placental 
site,  was  long  ago  pointed  out  by  Rokitansky  and  other  pathologists. 
This  theory  supposes  the  original  partial  depression  and  relaxation  of 
the  fundus.  How  this  is  often  produced  by  mismanagement  of  the 
third  stage  has  already  been  pointed  out ;  but  even  in  the  absence  of 
such  causes  it  may  result  from  strong  bearing-down  efforts  on  the  part 
of  the  patient,  or,  as  Duncan  holds,  from  the  absence  of  the  retentive 
pow^er  of  the  abdomen.  Indeed,  the  incomjiatibility  of  an  actively  con- 
tracted state  of  the  fundus  with  the  jiartial 
depression  which  is  essential,  according  to 
both  views,  for  the  production  of  invei-sion 
is  the  strongest  argument  in  favor  of  Dun- 
can's  theory. 

A  totally  d liferent  view  has  more  recently 
been  sustained  by  Dr.  Taylor  of  Xew  York, 
Avho  maintains  that  "spontaneous  active  in- 
version of  the  uterus  rests  upon  jirolonged 
natural  and  energetic  action  of  the  body  and 
fundus:  the  cervix,  the  lower  part,  yielding 
first,  is  thus  rolled  out,  or  everted,  or  doubled 
up,  as  there  is  no  obstruction  from  the  con- 
tractility of  the  cervix,  Mhich  is  at  rest  or 
functionally  paralyzed  ;  the  body  is  gradu- 
ally, sometimes  instantaneously,  forced  lower 
and  lower,  or  inverted." '  That  partial  inver- 
sion may  commence  at  the  cervix  was  jwinted 
out  by  Duncan  in  his  pa[K'r,  who  depicts  it 
in  the  accompanying  diagram  (Fig.  152), 
and  states  it  to  be  of  not  unfrequent  occur- 
It  is  not  impossible  that  occasionally  such  a  state  of  things 

1  ^'ew  York  Med.  Jonrn.,  1872,  vol.  xv.  p.  44y. 


Fig.  152. 


Illustratinp;  the  Commencement 
of  Inversion  at  the  Cervix. 
(After  Duncan.) 


rence. 


INVERSION  OF  THK    UTERUS.  453 

should  be  carried  on  to  complete  invei-siou.  But  there  are  serious 
objections  to  the  acceptance  of  Dr.  Taylor's  vie^v  that  such  is  the 
principal  cause  of  inversion,  since  the  ])roccss  above  described  Mould 
be  of  necessity  a  slow  and  long-continued  one,  whereas  nothing  is  more 
certain  than  that  inversion  is  generally  sudden  and  accompanied  by 
acute  symptoms  of  shock,  and  is  often  attended  by  severe  hemorrhage, 
which  could  not  occur  when  such  excessive  contraction  was  taking 
place. 

i  The  treatment  of  inversion  consists  in  restoring  the  organ  to  its 
natural  condition  as  soon  as  possible)  Every  moment's  delay  only  serves 
to  render  restoration  more  difficult,  as  the  inverted  portion  becomes 
swollen  and  strangulated ;  whereas  if  the  attempt  at  reposition  be 
made  immediately,  there  is  generally  comparatively  little  difficulty 
in  effecting  it.  Therefore,  it  is  of  the  utmost  imj^ortance  that  no 
time  should  be  lost  and  that  we  should  not  overlook  a  partial  or  in- 
complete inversion.  Hence  the  occurrence  of  any  unusual  shock,  pain, 
or  hemorrhage  after  delivery  without  any  readily  ascertained  cause 
should  always  lead  to  a  careful  vaginal  examination.  A  want  of  atten- 
tion to  this  rule  has  too  often  resulted  in  the  existence  of  partial  inver- 
sion being  overlooked  until  its  reduction  was  found  to  be  difficult  or 
impossible. 

In  attempting  to  reduce  a  recent  inversion  the  inverted  portion  of  the 
uterus  should  be  grasped  in  the  hollow  of  the  hand  and  pushed  gently 
and  firmly  upward  into  its  natural  position,  great  care  being  taken  to 
apply  the  pressure  in  the  proper  axis  of  the  pelvis,  and  to  use  counter- 
pressure  by  the  left  hand  on  the  abdominal  walls.  Barnes  lays  stress 
on  the  importance  of  directing  the  pressure  toward  one  side,  so  as  to 
avoid  the  promontory  of  the  sacrum.  fThe  common  plan  of  endeavor- 
ing to  push  back  the  fundus  first  has  been  well  shown  by  McClintock  ^ 
to  have  the  disadvantage  of  increasing  the  bulk  of  the  mass  that  has 
to  be  reduced,  and  he  advises  that  while  the  fundus  is  lessened  in  size 
by  compression  we  should  at  the  same  time  endeavor  to  push  up  first 
the  part  that  was  less  inverted — that  is  to  say,  the  portion  nearest  the 
OS  uteri.)  (^Should  this  be  found  impossible,  some  assistance  may  be 
derived  from  the  manceuvre  recommended  by  Merriman  and  others,  of 
first  endeavoring  to  push  up  one  side  or  wall  of  the  uterus,  and  then  the 
other,  alternating  the  up\vanrpressure  from  one  side  to  the  other  as  we 
advance.  It  often  ha])pens,  as  the  hand  is  thus  ap])lied,  that  the  uterus 
somewhat  suddenly  reiuverts  itself,  sometimes  with  an  audible  noise, 
much  as  an  India-rubber  bottle  would  do  under  similar  circumstances. 
When  reposition  has  taken  place  the  hand  should  be  kept  for  some 
time  in  the  uterine  cavity  to  excite  tonic  contraction,  or  a  stream  of  hot 
water  at  110°  F.  may  be  injected,  and  if  that  fails,  a  weak  solution  of 
percldoride  of  iron,  so  as  to  cause  tonic  contraction  of  the  uterus  and 
thus  prevent  a  recurrence  of  the  accident. 

It  is  hardly  necessary  to  point  out  how  much  these  manoeuvres  will 
be  facilitated  by  placing  the  patient  fully  under  the  influence  of  an 
anaesthetic. 

There  has  been  much  difference  of  opinion  as  to  the  management  of 
^  Diseases  of  Women,  p.  79. 


454  LABOR. 

tlie  plaoenta  in  cases  in  which  it  is  still  attached  when  inversif»n  occurs. 
Should  \vc  remove  it  before  attempting  rcpositifni,  or  slxtuld  we  first 
endeavor  to  reinvert  the  organ  and  snl)sc(|n('ntly  icmove  the  placenta? 
The  removal  ot"  the  })lacenta  certaiidy  nuich  diminishes  the  hulk  of  the 
inverted  portion,  and  therefore  renders  reposition  easier.  On  the  other 
hand,  if  there  be  much  hemorrhage,  as  is  so  frequently  the  case,  the 
removal  of  the  placenta  may  materially  increase  the  loss  of  blood. 
For  this  reason  most  authorities  recommend  that  an  endeavor  should 
be  made  at  a  reduction  before  })eeling  off  the  after-birth.  lint  if  any 
delay  or  difficulty  be  experienced  from  the  increased  bulk,  no  time 
should  be  lost,  and  it  is  in  every  way  better  to  remove  the  i)lacenta 
and  endeavor   to  reinvert  the  organ  as  soon  as  possible. 

Supposing  we  met  with  a  case  in  -which  the  existence  of  inversion 
has  been  overlooked  for  days,  or  even  for  a  week  or  two,  the  same  pro- 
cedure must  be  adopted ;  but  the  difficulties  are  much  greater,  and  the 
longer  the  delay  the  greater  they  are  likely  to  be.  Even  now,  how- 
ever, a  well-conducted  attempt  at  taxis  is  likely  to  succeed.  Should  it 
fail,  ^ve  must  endeavor  to  overcome  the  difficulty  by  continuous  pressure 
applied  by  means  of  caoutchouc  bags  distended  with  Mater  and  Jelt  "in 
the  vagina.  It  is  rarely  that  this  will  fail  in  comparatively  recent 
cases,  and  such  only  are  now  under  consideration.  It  is  likely  that  by 
pressure  applied  in  this  way  for  twenty-four  or  forty-eight  hours,  and 
then  followed  by  taxis,  any  case  detected  before  the  involution  of  the 
uterus  is  completed  may  be  successfully  treated. 

[Spontaneous  Reposition  of  the  Inverted.  Uterus. — After  all 
attempts  have  failed  to  replace  an  inverted  uterus,  ali'cady  too  nmch 
contracted  to  yield  to  the  pressui'e  employed,  (Nature  sometimes  accom- 
plishes the  work  herself,  as  proved  beyond  question  from  quite  a  num- 
ber of  well-established  cases,  several  of  which  belong  to  our  own  country! 
A  few  years  ago  I  saw  one  of  the  most  remarkable  on  record.  A  woman 
of  twenty-nine,  mother  of  three  children,  miscarried  at  six  and  a  half 
months  from  lifting.  From  the  time  of  her  delivery  she  was  subject 
to  weepings  of  blood,  and  at  times  to  more  or  less  severe  hemorrhages, 
one  of  the  last  of  which  nearly  proved  fatal.  This  condition  of  dis- 
ease had  lasted  three  years,  when  Dr.  Walter  F.  Atlee  was  called  in  to 
relieve  her  in  her  worst  hemorrhagic  attack,  and  found  her  uterus  in- 
verted, and  a  nodular  growth  upon  the  fundus  which  gave  out  an  offen- 
sive odor.  Thinking  the  disease  possibly  malignant,  and  believing,  in 
any  event,  that  to  save  the  woman  he  would  be  obliged  to  remove  the 
uterus,  he  called  a  consultation  and  ]M'eparcd  for  the  operation  ;  but 
when  the  patient  was  etherized,  placed  in  the  knee-elbow  position,  and 
Sims'  sjieculnm  introduced,  behold,  there  was  nothing  to  be  seen  in 
the  vagina  but  a  soft  dilated  cervix,  the  uterus  having  been  re])laeed 
by  atmospheric  ]iressure,  aided  perha])s  by  traction  on  the  uterine  at- 
tachments within.  ^\'hen  explored,  the  uterus  was  found  to  be  veiy 
soft  and  thin,  and  to  contain  some  hard  nodular  masses,  which  on 
removal  proved  to  be  portions  of  an  adherent  placenta.  The  hc4iior- 
rhage  cettsed  upon  the  reposition  and  cleaning  out  of  the  uterus,  and 
the  patient  made  a  good  recovery.     She  has  been  again  pivgnant. 

This  woman  was  antemic  to  a  marked  degree,  and  her  abdominal 


INVERSION    OF  THE    UTERUS.  455 

walls  so  thin  that  a  fing(;r  in  the  uterus  eould  readily  he  felt  ahove  the 
pubes.  There  is  not  the  slightest  doubt  about  the  inversion,  wliich  was 
proved  to  exist  a  short  time  before  the  change  of  posture  by  I'rof. 
Agnew,  who  made  a  finger  in  the  rectum  meet  another  above  the  pubes, 
and  there  was  no  fundus  between  them. 

Two'  cases  are  upon  record  where  rej)osition  was  llie  result  of"  falls, 
one  at  eight  months  and  the  other  aftcT  as  many  years.  Drs.  jNIoehring, 
0.  D.  Meigs,  H.  L.  Hodge,  and  Warrington  of  this  city  failed  to  re- 
place a  uterus,  and  the  woman  again  became  pregnant  in  about  six 
years,  aborting  with  a  three  months'  foetus  under  the  care  of  Dr.  War- 
rington. Dr.  Meigs  saw  a  second  case  with  Dr.  Levis,  in  which  there 
was  violent  flooding  followed  by  hemorrhages,  which  gradually  de- 
clined. After  her  retui'n  from  a  journey  AVest  she  became  pregnant 
and  bore  a  child.  Dr.  John  L.  Atlee  of  Lancaster  failed  to  replace 
the  uterus  of  a  woman,  but  she  recovered  spontaneously  and  bore  a 
child  a  year  afterward.^  Dr.  Johnson  F.  Hatch  of  Kent,  Connecticut, 
reported  a  case  in  a  letter  to  Dr.  C  D.  Meigs  in  which  inversion 
occurred  spontaneously  fourteen  or  fifteen  hours  after  labor.  After 
being  under  the  care  of  several  physicians,  she  had,  at  the  end  of  eigh- 
teen months,  two  severe  hemorrhagic  attacks,  after  which  she  improved, 
and  finally,  at  the  end  of  two  years  and  nine  months,  bore  a  child  of  9 
pounds  and  6  ounces. 

In  all  cases  spontaneous  reposition  appears  to  result  from  a  softening  1 
and  thinning  of  the  uterine  w^alls  as  the  result  of  anaemia  brought  on  | 
by  hemorrhages.     This  was  particularly  noticed  by  Boivin  and  Duges 
in  autopsies  of  women  dying  of  repeated  hemorrhages. — Ed.] 

['  See  Dalllez,  Essai  sur  le  Renverseineiil  de  la  Matrice,  Paris,  1805,  pp.  105-107.] 
P  Meigs'  Obstetrics,  1852,  Philada.,  p.  608.] 


PART  IV. 

OBSTETRIC    OPERATIONS. 


chaptp:r  I. 

INDUCTION   OF   PREMATURE    LABOR. 

History  of  the  Operation. — The  first  of  the  obstetric  operations  we 
have  to  consider  is  the  inchiction  of  j)remature  labor — an  operation 
■\\liieh,  like  the  use  of  forceps,  was  first  suggested  and  practised  in 
England,  and  the  recognition  of  which,  as  a  legitimate  procedure,  we 
also  chiefly  owe  to  the  labor  of  English  obstetricians,  in  spite  of  much 
opposition  both  at  home  and  abroad.  It  is  not  known  with  certainty  to 
whom  we  owe  the  original  suggestion,  Init  we  are  told  by  Denman  tiiat 
in  the  year  1756  there  was  a  consultation  of  the  most  eminent  i)hysi- 
cians  at  that  time  in  London  to  consider  the  advantages  which  might 
be  expected  from  the  operation.  The  proposal  met  with  formal  ajiproval, 
and  was  shortly  after  carried  into  practice  by  Dr.  Macaulay,  the  })atient 
lacing  the  wife  of  a  linen-draper  in  the  Strand.  From  that  time  it  has 
flourished  in  Great  Britain,  the  sjjhere  of  its  application  has  been  largely 
increased,  and  it  has  been  the  means  of  saving  many  mothers  and  chil- 
<lren  who  would  otherwise,  in  all  probability,  have  perished.  On  the 
Continent  it  was  long  before  the  operation  was  sanctioned  or  practised. 
Although  recommended  by  some  of  the  most  eminent  German  j>rac- 
titioners,  it  was  not  actually  performed  until  the  year  1804.  In 
France  the  opposition  w^as  long-continued  and  bitter.  Many  of  the 
leading  teachers  strongly  denounced  it,  and  the  Academy  of  ^Nlcdicine 
formally  discountenanced  it  so  late  as  the  year  1827.  Tlie  objections 
were  chiefly  based  on  religious  grounds,  but  partly,  no  doubt,  on  mis- 
taken notions  as  to  the  object  jiroposed  to  be  gained.  Although  fre- 
(piently  discussed,  the  o])eration  was  never  actually  carried  into  practice 
until  the  year  1831,  when  Stoltz  performed  it  with  success.  Since  that 
time  opposition  has  greatly  ceased,  and  it  is  now  employed  and  highly 
recommended  by  the  most  distinguished  obstetricians  of  the  French 
.schools. 

Objects  of  the  Operation. — In  inducing  premature  labor  we  ]>ro- 
]i0se  to  avoid  or  lessen  the  I'isk  to  which  in  certain  cases  the  mother  is 
exposed  l)y  delivery  at  term,  or  to  save  the  life  of  the  child,  Avliich 
might  otherwise  l)e  endangered.  /Hence  the  operation  may  be  indicated 
eitlier  on  account  of  the  mother  alone  or  of  the  child  alone,  or.  as  not 
unfro(|nently  ha]>pens,  of  l)oth  together) 


INDUCTION  OF  PREMATURE  LABOR.  457 

In  by  far  the  largest  nuiiilxn'  of  cases  tlic  operation  is  performed  on 
account  of  defective  propoi-tion  Ixitween  the  child  and  the  niatei'iial 
passages,  due  to  sonic  abnormal  condition  on  the  part  of  the  mother. 
This  want  of  proportion  may  depend  on  the  presence  of  tumors  either 
of  the  uterus  or  growing  from  the  pelvis.  But  most  fre({uently  it 
arises  from  deformity  of  the  pelvis  (]).  404),  and  it  is  needless  to  repeat 
what  has  been  said  on  that  point.  I  shall  therefore  only  briefly  refer 
to  a  few  more  uncommon  causes  which  occasionally  necessitate  its  i)er- 
formancc. 

One  of  these  is  an  habitually  large  or  over-firraly  ossified  foetal  head. 
Should  we  meet  with  a  case  in  which  the  labors  are  always  extremely 
difdcult  and  the  head  ap})arently  of  nnusual  size,  although  there  is  no 
apparent  want  of  space  in  the  i)elvis,  the  induction  of  labor  would  be 
perfectly  justifiable,  and  in  all  probability  would  accomplish  the  desired 
object.  In  such  cases  the  full  period  of  delivery  would  require  to  be 
anticipated  by  a  very  short  time.  A  week  or  a  fortnight  might  make 
all  the  difference  between  a  labor  of  extreme  severity  and  one  of  com- 
parative ease. 

There  is  a  large  class  of  cases  in  which  the  condition  of  the  mother 
indicates  the  operation.  Many  of  these  have  already  been  considered 
when  treating  of  the  Diseases  of  Pregnancy.  Amongst  them  may  be 
mentioned  vomiting  which  has  resisted  all  treatment,  and  which  has 
produced  a  state  of  exhaustion  threatening  to  prove  fatal ;  chorea,  albu- 
minuria, convulsions,  or  mania ;  excessive  anasarca,  ascites,  or  dyspnoea 
connected  with  disease  of  the  heart,  lungs,  or  liver,  which  may  be,  in  a 
great  measure,  caused  by  the  pressure  of  the  enlarged  uterus ;  in  fact, 
any  condition  or  disease  affecting  the  mother,  provided  only  we  are  con- 
vinced that  the  termination  of  pregnancy  would  give  the  patient  relief, 
and  that  its  continuance  would  involve  serious  danger.  /It  need  hardly 
be  pointed  out  that  the  induction  of  labor  for  any  suchNcauses  involves 
grave  responsibility,  and  is  decidedly  open  to  abuse  :  no  jiractitioner 
would,  therefore,  be  justified  in  resorting  to  it — especially  if  the  child 
have  not  reached  a  viable  age — without  the  most  anxious  consideration.! 
No  general  rules  can  be  laid  down.  Each  case  must  be  treated  on  its 
own  merits.  It  is  obvious  that  the  nearer  the  patient  is  to  the  full  period, 
the  greater  will  be  the  chance  of  the  child  surviving,  and  the  less  hesita- 
tion need  then  be  felt  in  consulting  the  interest  of  the  mother. 

In  another  class  of  cases  the  operation  is  indicated  by  circumstances 
affecting  the  lifejpf  the  child  alone.  Of  these  the  most  common  are 
those  in  which  the  child  dies,  in  several  successive  pregnancies,  before 
the  termination  of  utero-gestation.  This  is  generally  the  result  of  fatty, 
calcareous,  or  syphilitic  degeneration  of  the  placenta,  Mhich  is  thus  ren- 
dered incapable  of  performing  its  functions.  These  changes  in  the  pla- 
centa seldom  commence  until  a  comparatively  advanced  period  of  preg- 
nancy ;  so  that  if  labor  be  somewhat  hastened  we  may  hope  to  enable 
tlie  patient  to  give  birth  to  a  living  and  healthy  child.  The  experience 
of  the  mother  will  indicate  the  period  at  which  the  death  of  the  fretus 
has  formerly  taken  place,  as  she  would  then  have  a])preciated  a  difier- 
ence  in  her  sensations,  a  diminution  in  the  vigor  of  the  fetal  move- 
ments, a  sense  of  weight  and  coldness,  and  similar  signs.     For  some 


458  OBSTETRIC  OPERATIOyS. 

weeks  before  the  time  at  wliidi  this  eluiii'.'-c  lias  heeii  e.\|t(  riciiccd  we 
slumkl  careful Iv  aiisi-iiltate  llie  I'u'tal  heart  {"r»»iii  day  to  day,  and  in  must 
cases  the  a])])i'oach  oi'  dan<rer  will  be  indicated,  sullieientlv  soon  to 
enable  us  to  interi'ere  with  success,  by  tumultuous  and  irre^idar  pulsa- 
tions or  a  iiiilui'c  in  their  strength  and  t"re(|uency.  On  the  detection 
''of  these,  or  on  the  mother  feelin<(  that  the  movements  of  the  child  are 
becomino-  less  strong,  the  operation  should  at  once  be  performed. 
Simpson  also  induced  premature  labor  with  success  in  a  patient  who 
had  twice  oiven  birth  to  hydrocephalic  children.  In  the  third  preg- 
uancy,  which  he  terminated  l)efore  the  natiu-al  peri(xl,  the  child  was 
iwell-formed  and  healthy. 

Some  obstetricians  have  ])ro])osed  to  induce  labor  with  the  view  of 
saving  the  child  when  the  mother  was  suffering  from  mortal  disease. 
This  indication  is,  however,  so  extremely  doubtful  from  a  moral  point 
of  view  that  it  can   hardly  be  considered  as  ever  ju.-tiHaijle. 

Various  Methods  of  Inducing-  Labor. — The  means  adopted  i'or  the 
inductit)n  (jf  labor  are  very  numerous.  Some  of  them  act  through  the 
I  maternal  circulation)  as  the  administration  of  ergot  and  other  oxytocics ; 
others  by  their  power  of  exciting  reflex  action,  or 'by  interfering  with 
the  integrity  of  the  ovum;  or  by  a  combination  of  both,  as  the  vaginal 
douche,  separation  of  the  membranes  from  the  uterine  walls,  puncture 
of  the  ovum,  dilatation  of  the  os,  stimulating  enemata,  or  irritation  of 
the  breasts.  The  former  class  are  never  employed  in  modern  obstetric 
practice.  Of  the  latter,  some  offer  special  advantages  in  particular 
cases,  but  none  are  equally  ada])ted  for  all  emergencies.  Often  a  com- 
bination of  more  methods  than  one  Mill  be  found  most  useful.  1  shall 
mention  the  various  methods  in  use,  and  discuss  briefly  the  relative 
advantages  and  disadvantages  of  each. 
/  Puncture  of  Membranes. — The  evacuation  of  the  liquor  amnii  by 
)  the  puncture  of  the  membranes  was  the  first  method  practised,  and  was 
/  that  recommended  by  Denman  and  all  the  earlier  writers.  It  is  the 
\  most  certain  Mhich  can  be  em])loyed,  as  it  never  fails,  sooner  or  later, 
to  induce  uterine  contractions.  There  arc  however,  several  disadvan- 
tages connected  with  it  which  are  sufficient  to  contraindicate  its  use  in 
the  majority  of  cases.  It  is  uuceftain  as  regards  the  time  taken  in 
producing  the  desired  effect,  pains  sometimes  coming  on  within  a  few 
hours,  but  occasionally  not  until  several  days  have  elapsed.  The  con- 
tracting walls  of  the  uterus  press  directly  on  the  body  of  the  child, 
M'hich,  being  frail  and  immature,  is  less  able  to  bear  the  jn'cssure  than 
at  the  full  period  of  pregnancy.  Hence  it  involves  great  risk  to  the 
fcetus.  Besides,  the  escaj^e  of  the  water  does  away  with  the  fluid 
w^lge  so  useful  in  dilating  the  os,  and  should  version  be  neccasarv 
from  mal presentation — a  complication  more  likely  to  occur  than  in 
natural  lal)or — the  operation  would  have  to  be  ])erforme<l  under  very 
unfavorable  conditions.  (These  objections  are  sufficient  to  justify  the 
ordinary  opinion  that  this  procedure  should  not  be  adopted  unless  other 
means  have  been  tried  and  failed.)  Every  now  and  tlien  cases  are  met 
with  in  which  it  is  extremely  difficult  to  arouse  the  uterus  to  action, 
and  under  such  circumstances,  in  spite  of  its  drawbacks,  this  inethrHl 
will   be  found  to  be  very  valuable.   (When  the  operation    has   to  be 


INDUCTION  OF  PREMATURE  LABOR.  459 

performetl  before  tlie_  child  is  viable — that  is,  before  the  seventh 
luoiith — these  objections  do  not  hold,  and  then  it  is  the  simplest  and 
readiest  procedure  we  can  adoptjfc  (jndeed,  in  producin<^  early  alxn-tion 
no  other  is  practical)le.j  The  operation  itself  is  most  simple,  recpiiriiig 
only  a  ({uill,  stiletted  catheter,  or  other  suitable  instrument  to  be 
passed  up  to  the  os,  carefully  guarded  by  the  fingers  of  the  left  hand 
previously  introduced,  and  to  be  pressed  against  the  membranes  until 
perforation  is  accomplished.  Meissner  of  Leipsic  has  ])ro})osed  as  a 
modification  of  this  plan  that  the  membranes  should  Ijc  punctured 
obliquely  three  or  four  inches  above  the  os,  so  as  to  admit  of  a  gradual 
and  partial  escape  of  the  amniotic  fluid,  thus  lessening  the  risk  to  the 
child  from  pressure  by  the  uterus.  For  this  purpose  he  employed  a 
curved  silver  canula  containing  a  small  trocar,  which  can  be  prcyected 
after  introduction.  The  risk  of  injuring  the  uterus  by  such  an  instru- 
ment would  be  considerable,  and  we  have  other  ancl  better  means  at 
our  command  which  render  it  unnecessary.  When  we  require  to  pro- 
duce early  abortion,  it  would  be  well  not  to  attemjjt  to  puncture  the 
membranes  with  a  sharp-pointed  instrument.  The  object  can  be 
effected  with  certainty  and  greater  safety  by  passing  an  ordinary 
uterine  sound  through  the  os  and  turning  it  round  once  or  twice. 

Administration  of  Oxytocics. — The  administration  of  ergot  of 
rye,  either  alone  or  combined  with  borax  and  cinnamon,  has  been 
sometimes  resorted  to.  This  practice  has  been  principally  advocated 
by  Ramsbotham,  who  was  in  the  habit  of  exhibiting;  scruple  doses  of 
the  powdered  ergot  every  fourth  hour  until  delivery  took  place.^  Some- 
times he  found  that  as  many  as  thirty  or  forty  doses  were  required  to 
effect  the  object;  occasionally  labor  commenced  after  a  single  dose. 
Finding  that  the  infantile  mortality  was  very  great  when  this  method 
was  followed,  he  modified  it,  and  administered  two  or  three  doses  only, 
and  if  these  proved  insufficient  he  punctured  the  membranes.  There 
can  be  no  doubt  that  ergot  possesses  the  power  of  inducing  uterine  con- 
tractions. The  risk  to  the  child  is,  however,  quite  as  great  as  when  the 
membranes  are  punctured  ;  for  not  only  is  it  subject  to  injurious  pressure 
from  the  tumultuous  and  irregular  contractions  which  the  ergot  pro- 
duces, but  the  drug  itself,  when  given  in  large  doses,  seems  to  exert 
a  poisonous  influence  on  the  foetus.  For  these  reasons  ergot  may 
properly  be  excluded  from  the  available  means  of  inducing  labor. 

Methods  Acting-  Indirectly  on  the  Uterus. — Various  methods 
have  been  recommended  which  act  indirectly  on  the  uterus,  the  source 
of  irritation  being  at  a  distance.  Thus,  D'Outrepont  used  frequently 
repeated  abtlominal  frictions  and  tight  bandages.  Scanzoni,  remem- 
bering the  intimate  connection  between  the  mammte  and  uterus,  and 
the  tendency  which  irritation  of  the  former  has  to  induce  contraction 
of  the  latter,  recommended  the  frequent  application  of  cup])ing-glasses 
to  the  brgasts.  Radford  and  others  have  employed  galvanism.  "Stim- 
ulating enemata  have  been  emj^loyed.  All  these  methods  have  occa- 
sionally jn'oved  successful,  and,  unlike  the  former  plans  we  have 
.mentioned,  they  are  not  attended  by  any  special  risk  to  the  child. 
^rjiThey  are,  however,  much  too  uncertain  to  be  relied  on,  besides  being 
//jf;  irksome  both  to  the  patient   and  practitioner. 


460 


OBSTETRIC  OPERATIONS. 


Fig.  153. 


The  artificial  dilitation  of  the  os  uteri  in  imitation  of"  it.s  natural 
opening  in  labor  wa.s  first  practised  by  Kliige.     He  was  in  the  habit  of 
])a.'Nsing  within  the  os  a  tent  made  of"  eompres-sed  sponge,  and  allowing 
it  to  dilate  bv  imbibition  of"  fluid.      If"  labor  were  not  provoked  within 
twentv-t'our  hours  he  removed  it  and  introduced  one  of"  larger  dimen- 
sion.s,  changing  it  as  often  as  was  necessary  until  his  object  was  aceom- 
pli.shed.     Although  this  operation  seldom  failed  to  induce  labor,  it  had 
the  di.^advantage  of  occupying  an  indefinite  time,  and  the    irritation 
j)roduced  was  often  painful  and  annoying.     Dr.  Keiller  of  lulinburgh 
Mas  the  first  to  suggest  the  use  of  ca()utchoii£  bags  distended  by  air  as  a 
means  of  dilating  the  os.     Tin's  ])lan'7iasnbeen  perfected  by  Dr.  Barnes 
in  his  well-known  dilators,  Mhich  arc  of  great  u.se  in  many  cases  in 
which  artificial  dilatation  of  the  cervix  is  necessary.     They  consist  of  a 
series  of  India-rubber  bags  of  various  sizes,  with  a  tube  attached  (Fig.  153) 
through  which  water  can  be  injected  by  an  ordinary  Higgin.son's  syringe. 
Thev  have  a  small  ])ouch  fixed  externally  in  Avhich  a  sound  can  be 
placed,  w  as  to  facilitate  their    introduction.     ^\'hen    distended  with 
water  the  bags  assume  somewhat  of  a  fiddle  shape,  bulging  at  both 
extremities,  which  ensures  their  being  retained  within  tlie  os.     When 
first  introduced  into  practice  as  a  means  of  inducing  labor  it  was  thought 
that  this  method  gave  a  complete  control  over  the  process,  so  that  it 
could  be  concluded  within  a  definite  time  at  the  will  of  the  operator. 
The  experience  of  those  Mho  have  used  it  much  has  certainly  not  justi- 
fied this  anticipation.     It  is  true  that  occasionally  con- 
tractions intervene  M'ithin  a  few  hours  after  dilatation 
has  been  commenced,  but,  on  the  other  hand,  the  uterus 
often  responds  very  imjierfectly  to  this  kind  of  stim- 
ulus, and  the  bags  may  be  inserted  for  many  coui^ecu- 
tive  hours  Mithout  the  desired  result  supervening,  the 
]>uncture  of  the  membranes  being  eventually  neces.>^ary 
in  order  to  hasten  the  process.    (Indeed,  my  omii  expe- 
rience Mould  lead  me  to  the  conclusion  that  as  means  of 
evoking  uterine  contraction  cervical  dilatation  is  very 
unsatisfactory.]  (Dr.  ]]arnes  himself  has  evidently  .seen 
rea.son  to  modify  his  original  vicMs,  for  while  he  at 
first  talked  of  the  bags  as  enabling  us  to  induce  labor 
M'ith  certainty  at  a  given  time,  he  has  since  recommended 
that  uterine  action  sliould  be  first  provoked  by  other 
means,  the  dilators  being  subsequently  used  to  accele- 
rate the  labor  thus  brought  on.   The  bags  thus  employed 
find,  as  I  believe,  their  mo.-;t  useful  and  a  very  valuable 
application  ;  l)ut  when  used   in  this  M'ay  they  cannot  be  considered  as 
a  means  of  originating  uterine  action.)    A  subsidiary  objection  to  the 
bags  is  the  risk  of  displacing  the  presenting  part.     I  have,  for  example, 
introduced  them  M'hen  the  head  Mas  presenting,  and  on  their  removal 
found  the  .'ihoulder  lying  over  the  os.     It  is  not  difficult  to  understand 
hoM- the  continuous  pressure  of  a  di.stended  bag  in  the  internal  os  might 
easilv  push  away  the  head,  M'hich   is  so  readily  movable  .•^o  long  as  the 
membranes  are  unruptured.     Still,  if  labor  be  in  progress  and  the  os 
insufficiently  dilated,  the  possibility  of  this  occurrence  is  not  a  sufficient 


Barnes  Bag  for 
Dilating  the 
Cervix. 


INDUCTION  OF  PREMATURE  LABOR.  461 

reason  for  not  availing  ourselves  of  the  undouljtedly  valuable  assistance 
wliieli  the  dilators  are  eapalile  of  giving. 

Separation  of  the  Membranes. — Some  processes  for  inducing  labor 
act  directly  on  the  ovum  by  separating  the  membranes  to' a  greater  or 
less  extent  from  the  uterine  walls.  The  first  procedure  of  the  kind  was 
reconnnended  by  Dr.  Jlamilton  of  Ivlinburgh,  and  consisted  in  the 
gradual  separation  of  the  membranes  fur  one  or  two  inches  all  round 
the  lower  segment  of  the  uterus.  To  reach  them  the  finger  had  to  be 
gently  insinuated  into  the  interior  of  the  os,  which  was  gradually  dilated 
to  a  sufficient  extent  by  a  series  of  successive  operations  repeated  at 
intervals  of  three  or  four  lipurs.  When  this  had  been  accomplished 
the  forefinger  was  inserted  and  swept  round  between  the  membranes 
and  the  uterus,  but  it  was  frequently  found  necessary  to  introduce  the 
greater  ]iart  of  the  hand  to  effect  the  object;  and  sometimes  even  this  was 
not  sufficient,  and  a  female  catheter  or  other  instrument  had  to  be  used 
for  the  purpose.  The  method  was  generally  successful  in  bringing  on 
labor,  but  it  now  and  then  failed,  even  in  Dr.  Hamilton's  hands.  It  is 
certainly  based  on  correct  principles,  but  it  is  tedious  and  painful  both 
to  the  practitioner  and  the  patient,  and  very  uncertain  in  its  time  of 
action.     For  these  reasons  it  has  never  been  much  practised. 

Vaginal  and  Uterine  Douches. — In  the  year  1 836,  Kiwiseh  sug- 
gested a  plan  which  from  its  simplicity  has  met  with  much  approval. 
It  consists  in  projecting  at  intervals  a  stream  of  warm  or  cold  water 
against  the  os  uteri.  Its  action  is  doubtless  complex,  (jviwisch  himself 
believed  that  relaxation  of  the  soft  parts  through  the  imbibition  of 
water  was  the  determining  cause  of  labor)  (Simpson  found  that  the 
method  failed  unless  the  w^ater  mechanically  separated  the  membranes 
from  the  uterine  walls.  Besides  this  effect,  it  probably  directly  induces 
reflex.iietion  by  distending  the  vagina  and  dilating  the  os.  In  using  it, 
it"Tias  been  customary  to  administer  a  doucKelAvice  daily,  and  more 
frequently  if  rapid  effects  be  desired.  The  number  required  varies  in 
different  cases.  The  largest  number  Kiwiseh  found  it  necessary  to  use 
was  seventeen,  the  smallest  five.  The  average  time  that  elapses  before 
labor  sets  in  is  four  days.  Hence  the  method  is  obviously  useless  when 
raj)id  delivery  is  required. 

Dr.  Cohen  of  Hamburg  introduced  an  important  modification  of  the 
process  Avliich  has  been  considerably  jiractised.  It  consists  in  passing  a 
silver  or  gum-elastic  catheter  some  inches  within  the  os,  between  the 
membranes  and  the  uterine  walls,  and  injecting  the  fluid  through  it 
directly  into  the  cavity  of  the  uterus.  He  used  creasote  or  tar-water, 
and  injected  without  stopping  until  the  patient  complained  of  a  feeling 
of  distension.  Others  have  found  the  plan  equally  efficacious  when  thev 
only  employed  a  small  quantity  of  plain  water,  such  as  seven  or  eight 
ounces.  Professor  Lazarewitch  of  St.  Petersburg  is  a  strong  advocate 
of  this  method.  He  believes  that  uterine  action  is  evoked  nuich  more 
rapidly  and  certainly  if  the  water  be  injected  near  the  fundus,  and  he 
has  contrived  an  instrument  for  the  purpose  with  a  long  metallic  nozzle. 

Dangers  of  these  Plans. — So  many  fatal  cases  have  followed  these 
methods  that  it  cannot  be  doubted  that,  in  spite  of  their  eertainty  and 
simplicity,  there  is  an  element  of  risk  in  them  that  should  not  be  over- 


462  OBSTETiur  oj'j-n.iTioys. 

looked.  Many  of  these  are  recorded  in  IJarnes'  work,  and  lie  conM-s  to 
the  eonelnsion,  which  the  facts  uncjnestionaidy  jnstiiy,  that  "the  douche, 
whether  vauinai  nr  inti'a-ntei'ine,  onti;ht  to  he  ai)sohit('ly  condemned  as  a 
nu'ans  of"  inthicinti'  hihoi-."  'i'lic  precise  reason  of  the  dan<r('r  is  not  very 
obvious.  Sudden  stretchin«>-  of  the  uterine  walls,  |H"o(hicin<:-  shock,  has 
been  supposed  to  have  caused  it ;  but  in  many  of  the  fatal  cases  the 
symptoms  have  been  rather  those  attending  the  pa&sage  of  ajr  into  the 
veins,  and  it  is  easy  to  understand  how  air  may  have  been  intrcMluccd 
in  this  way  into  the  large  uterine  sinuses. 

Sim})son  and  Scanzoni  have  l)oth  tried  with  success  the  injection  of 
carbonic-acid  y-as  into  the  vagina.  Fatal  results  have,  however,  fol- 
lowed  its  employment,  and  k5im})son  has  expressed  an  oj)inion  that  the 
ex|)eriment  should  not  be  re})eated. 

Sim})son  originally  induced  labor  by  pas-sing  the  uterine  sound  within 
the  OS  and  up  toward  the  fundus,  and,  when  it  had  been  inserted  to  a 
sufficient  extent,  moving  it  slightly  from  side  to  side,  lie  was  led  to 
adopt  this  procedure  in  the  belief  that  we  might  thus  closely  imitate  the 
separation  of  the  deeidua  which  occurs  previous  to  labor  at  term. 
Uterine  contractions  were  induced  with  certainty  and  ease,  but  it  was 
found  impossible  to  foretell  what  time  might  ela})sc  between  the  com- 
mencement of  labor  and  the  operation,  which  had  fre(juently  to  l)e 
])erfornied  more  tlian  once.  (He  subsequently  modified  this  ])roce<lurc 
by  introducing  a  flexible  male  catheter  without  a  stilette,  which  he 
allowed  to  remain  in  the  uterus  until  contractions  were  excited.  )  This 
plan  is  much  used  in  Germany,  and  is  now  that  which  is  also  most 
frequently  adopted  in  England.  It  is  simple  and  very  efficacious, 
pains  coming  on  almost  invariably  within  twenty-four  honi's  after  the 
catheter  or  bougie  is  introduced.  A  theoretical  objection  is  the  possi- 
bility of  the  catheter  separating  a  portion  of  the  })lacenta  and  giving 
rise  to  hemorrhage ;  but  in  jM'actice  this  has  not  been  found  to  occur, 
and  the  risk  luight  generally  be  avoided  by  introducing  a  catheter  at  a 
distance  from  the  ])laccnta,  the  })robable  situation  of  which  has  been 
ascertained  by  auscultation.  The  more  deej^ly  the  catheter  is  introduced, 
the  more  certain  and  rapid  is  its  effect,  and  not  less  than  seven  inches 
should  be  pushed  up  within  the  os.  It  is  not  always  easy  to  insert  it  so 
far,  especially  if  a  flexible  catheter  be  used,  which  is  apt  to  be  too  pliable 
to  pass  upward  with  ease.  (A  solid  bougie — male  urethral  bougie — 
sh(»uld  therefore  be  employed,  and  I  have  found  its  introduction  gi'catly 
facilitated  by  anfcsthetizing  the  patient  and  ])assing  the  greater  })art  of 
the  hand  into  the  vagina.)  In  this  way  it  can  be  ])ushe(l  in  very  gently 
and  without  any  risk  of  injury  to  the  uterus.  There  is  some  chance  of 
rn|)turing  the  membranes  while  pushing  it  upward.  This  accident, 
indeed,  cannot  always  be  avoided,  even  when  the  greatest  care  is  taken  ; 
but  when  it  occurs  the  puncture  will  be  at  a  distance  from  the  os,  so 
that  a  small  portion  only  of  the  liquor  amnii  will  escape,  and  this  can 
sea  reel  V  be  considered  a  serious  objection.  It  is  alwavsan  advantage  to 
allow  the  pains  to  come  on  gradually  and  in  imitation  of  natural  labor. 
Therefore,  if,  after  the  bougie  has  been  inserted  for  a  sufficient  time, 
uterine  contractions  come  on  sufficiently  strongly,  we  may  leave  the  ca.se 
to  be  terminated  naturally,  or  if  they  be  comparatively  feeble  we  may 


INDUCTION  OF  PREMATURE  LABOR.  403 

resort  to  accelerative  ])roc('(liiros — viz,  dilatation  of"  tlio  cervix  by  the 
fluid  bag.s,  and  .suhsequciilly  tlu;  j)un('tur('  of  the  nicnibranes.  Jii  this 
way  we  have  the  labor  completely  under  control ;  and  I  believe  this 
method  will  commend  itself"  to  those  who  have  experience  of  it  as  the 
simplest  and  most  certain  mode  of  inducing  labor  yet  known,  and  the 
one  most  closely  imitating  the  natural  ])rocess.  Of  late  I  liave  been  in 
the  habit  of  combining  dilatation  of  the  cervix  with  this  method  by 
means  of  a  well-carbolizcd  sponge  tent  passed  into  the  cervix  after  the 
bougie  is  in  ])Osition.  In  ten  or  twelve  hours,  Avhen  the  tent  and  bougie 
are  removed,  the  cervix  is  found  well  dilated  and  ready  for  the  j^assage 
of  the  child. 

It  should  not  be  forgotten  that  tlie  child  is  immature,  and  that 
unusual  care  is  likely  to  be  required  to  rear  it  successfully.  We  shoukl 
therefore  be  careful  to  have  at  hand  all  the  usual  means  of  resuscita- 
tion ;  and,  as  the  mother  may  not  be  able  to  nurse  at  once,  it  would  be 
a  good  precaution  to  have  a  healthy  wet-nurse  in  readiness. 

[The  most  serious  objection  to  the  induction  of  premature  labor  is 
the  frightful  infantile  mortality  :  that  of  the  mothers  is  quite  low  in 
skilful  hands.  The  late  Dr.  Cesare  Belluzzi  of  Bologna  recorded  112 
cases,  with  8  deaths  of  women  and  15  of  the  foetuses — 42  patients  were 
treated  in  his  private  practice,  and  70  in  the  Maternity  of  Bologna.  In 
9  patients  labor  was  induced  because  of  disease  in  the  mother ;  in  1  it 
was  brought  on  because  the  foetus  had  usually  died  in  the  ninth  month 
of  former  j)regnancies  ;  and  in  102  the  pelvis  was  contracted.  Of  these 
102,  6  died — 3  out  of  38  in  private  practice,  and  3  out  of  64  in  the 
hospital.  Of  the  9  women  operated  upon  because  of  serious  disease,  7 
recovered,  35  out  of  42  infants  were  delivered  alive  in  private  ])rac- 
tice,  and  62  out  of  70  in  the  Maternity.  The  prolonged  vitality  of  the 
foetus  is  largely  dependent  upon  the  period  in  gestation  wdiich  is  chosen 
for  the  operation :  the  later  the  delivery,  the  better  is  the  prospect  of 
ultimate  safety.  But  a  small  proportion  of  the  children  reach  matur- 
ity. Of  32  delivered  alive  in  hospital  in  a  period  of  less  than  ten 
years  under  Dr,  Belluzzi,  27  were  dead  before  the  expiration  of  the  first 
year,  and  29  in  all  within  two  years  of  birth.  Dr.  Ludwig  AViuckel 
of  ]\Iulheim,  Germany,  has  published  a  record  of  25  deliveries  in  women 
who  were  all  the  subjects  of  contraction  of  the  pelvis.  These  patients 
all  recovered:  14  children  w^ere  still-born  and  13  were  living;  of  the 
latter,  only  7  were  alive  at  the  end  of  two  weeks.  With  the  "co(/- 
vciifie"  of  Auvard  much  better  results  in  saving  foetal  life  in  materni- 
ties ought  now  to  be  attained, — Ed,] 


b 


/ 


i 


464  OBSTETRIC  OPERA  Tloy.S. 


chapti:r  II. 

TURNING. 

History  of  the  Operation. — Turnino; — by  which  Me  mean  the  alter- 
ation ot"  tlie  position  of  the  f'a?tu.s  and  tlie  substitution  of  some  other 
portion  of  tlie  body  for  that  originally  presenting — is  one  of  the  m(xst 
important  of  obstetric  ojierations,  and  merits  careful  study.  It  is  also 
one  of  the  most  ancient,  and  was  evidently  known  to  the  Greek  and 
Roman  physicians.  Up  t(j  the  fifteenth  century  cephalic  version — that 
in  which  the  head  of  the  foetus  is  brouglit  over  the  os  uteri — was  almost 
exclusively  practised,  M-hen  Pare  and  his  pupil  Guillemeau  taught  the 
])r()])riety  of  bringing  the  feet  down  first.  It  was  by  the  latter  j)hysi- 
cian  especially  that  the  steps  of  the  operation  were  clearly  defined  ;  and 
the  French  have  undoubtedly  the  merit  Ijotli  of  pei-fecting  its  perform- 
ance and  of  establishing  the  indications  which  should  lead  to  its  use. 
Indeed,  it  was  then  much  more  frequently  performed  than  in  later  times, 
since  no  other  means  of  effecting  artificial  delivery  were  known  which 
did  not  involve  the  death  of  the  child  ;  and  jiractitioners  doubtless 
acquired  great  skill  in  its  performance,  and  were  inclined  to  overrate  its 
importance  and  extend  its  use  to  unsuitable  cases.  An  opposite  error 
was  fallen  into  after  the  invention  of  the  forceps,  which  for  a  time  led 
to  the  abandonment  of  turning  in  certain  conditions  for  which  it  was 
well  adapted,  and  in  wdiich  it  has  only  of  late  years  been  again  prac- 
tised. 

Cephalic  version  has,  since  Pare  wrote,  been  recommended  and 
practised  from  time  to  time,  but  the  difficulty  of  performing  it  satis- 
factorily was  so  great  that  it  never  became  an  established  operation. 
Dr.  Braxton  Hicks  has  perfected  a  method  by  which  it  can  be  accom- 
plished with  greater  ease  and  certainty,  and  which  rendei"s  it  a  legiti- 
mate and  satisfactory  resort  in  suitable  cases.  To  him  we  are  also 
indebted  for  intrfiducing  a  method  of  turning  without  ])assing  the  entire 
hand  into  the  cavity  of  the  uterus,  which  under  favorable  circumstances 
is  not  oidy  easy  of  performance,  but  deprives  the  operation  of  one  of 
its  greatest  dangers. 

The  possibility  of  effecting  vei'sion  by  external  manipulation  has  been 
long  known,  and  was  distinctly  referred  to  and  recommended  by  Dr. 
John  I\'chey '  so  far  back  as  the  year  1G98.  Since  that  time  it  has  been 
strongly  advocated  l)y  Wigand  and  his  followers;  and  vju'ious  authors 
in  England,  notal)ly  Sir  James  Simpson,  have  referred  to  the  advantage 
to  be  derived  from  external  manipulation  assisting  the  hand  in  the  iiUe- 
rior  of  the  uterus.  In  1804,  Dr.  AVright  of  Cincinnati  advocated  the 
application  of  the  bimanual  method  in  arm  and  shoulder  presentations, 
chiefly  with  the  view  of  effecting  cephalic  version.     To  Dr.   Hicks, 

■  The  Complete  Midui/e^s  Practice,  p.  142. 


TURNING.  465 

liowever,  incontestably  belongs  the  merit  of  liaving  been  the  first  dis- 
tinctly to  show  t)ie  possibility  of  effecting  complete  version  in  all  cases 
ill  which  the  operation  is  indicated  by  combined  external  and  internal 
manipulation,  of  laying  down  definite  rules  for  its  practice,  and  for  thus 
popularizing  one  of  the  greatest  improvements  in  modern  midwifery. 

rriie  operation  is  entirely  dependent  for  success  on  the  fact  that  the 
child  in  utero  is  freeh^ movable,  and  that  its  position  may  be  artificially 
altered  with  facility.^  As  long  as  the  membranes  are  unruptured  and 
the  foetus  is  floating  in  the  surrounding  fluid  medium  It  is  liable  to  con- 
stant changes  in  position,  as  may  be  readily  demonstrated  in  the  latter 
months  of  pregnancy,  and  the  operation  under  these  circumstances  may 
be  performed  with  the  greatest  facility.  Shortly  after  the  liquor  amnii 
has  escaped  there  is  still,  as  a  rule,  no  great  difficulty  in  effecting  ver- 
sion, but  as  the  body  is  no  longer  floating  in  the  surrounding  liquid  its 
rotation  must  necessarily  be  attended  with  some  increased  risk  of  injury 
to  the  uterus.  If  the  liquor  amnii  has  been  long  evacuated  and  the 
muscular  structure  of  the  uterus  be  strongly  contracted,  the  foetus  may 
be  so  firmly  fixed  that  any  attempt  to  move  it  is  surrounded  with  the 
greatest  difficulties,  and  may  even  fail  entirely,  or  be  attended  with  such 
risks  to  the  maternal  structures  as  to  be  quite  unjustifiable. 

Version  may  be  required  either  on  account  of  the  mother  or  child 
alone,  or  it  may  be  indicated  by  some  condition  imperilling  both  and 
rendering  immediate  delivery  necessary.  The  chief  cases  in  which  it  [/ 
is  resorted  to  are  those  of  transverse  presentation,  where  it  is  absolutely  ) ) 
essential ;  accidental  or  uuavoi(la1)le  hemorrhage ;  certain  cases  of  con- 
tractedjDelvis ;  and  some  complications,  especially  prolapse  of  the  funis. 
The  special  indications  for  the  operation  have  been  separately  discussed 
under  these  subjects. 

Statistics  and  Dangers  of  the  Operation. — The  ordinary  statisti- 
cal tables  cannot  be  depended  on  as  giving  any  reliable  results  as  to  the 
risks  of  the  operation.  Taking  all  cases  together.  Dr.  Churchill  esti-, 
mates  the  .maternal  mortality  at  1  in  16  J  and  the/ infantile  as  1  in  3.^ 
Like  all  similar  statistics,  they  are  open  to  the  objection  of  not  dis- 
tinguishing between  the  results  of  the  operation  itself  and  of  the  cause 
which  necessitated  interference.  Still,  they  are  sufficient  to  show  that 
the  operation  is  not  free  from  grave  hazards,  and  that  it  must  not  be 
undertaken  without  due  reflection.  The  principal  dangers  will  be  dis- 
cussed as  we  proceed.  It  may  suffice  to  mention  here  that  those  to  the 
mother  must  vary  with  the  period  at  which  the  operation  is  undertaken. 
If  version  be  performed  early,  before  the  rupture  of  the  membranes, 
or,  in  favorable  cases,  without  the  introduction  of  the  hand  into  the 
interior  of  the  uterus,  the  risk  must  of  course  be  infinitely  less  than 
in  those  more  formidable  cases  in  which  the  M'aters  have  long  escaped 
and  the  hand  and  arm  have  to  be  passed  into  an  irritable  and  con- 
tracted uterus.'  But  even  in  the  most  unfavorable  cases  accidents  may 
be  avoided  if  the  operator  bear  constantly  in  mind  that  the  princi- 
pal danger  consists  in^  laceration  of  the  uterus  or  vagina) from  undue 
force  being  employed  or  from  the  hand  and  arm  not  being  introduced 
in  the  axis  of  the  passages.  There  is  no  operation  in  which  gentleness, 
absence  of  all  hurry,  and  complete  presence  of  miud  are  so  essential. 

30 


( 


4G6  OBSTETJUC  OPERATIOSS. 

A  fCi'taln  uumbor  of  cases  end  fatally  from  shook  or  exhaustion  <>r 
from  snl)si'(jnent  complications.  As  rcoards  the  child  the  mcjitalityj 
is  little,  if  at  all,  greater  than  in  original  hreecii  and  footling  prescn-' 
tations.  Xor  is  there  any  good  reason  why  it  should  he  so,  seeing  that' 
cases  of  turning  after  the  feet  are  brought  througii  the  os  are  virtually 
reduced  to  those  of  feet  presentation,  and  that  the  mere  version,  if 
effected  sufliciently  soon,  is  not  likely  to  add  materially  to  the  risk  to 
Avhich   the   child   is  exposed. 

The  possibility  of  etlecting  version  by  external  manipulation  has 
been  recognized  by  various  authors,  and  Avas  made  the  subject  of  an 
excellent  thesis  by  Wigand,  -who  clearly  described  the  manner  of  per- 
forming the  operation.  In  spite  of  the  manifest  advantages  of  the 
procedure,  and  the  extreme  facility  with  which  it  can  be  accomplished 
in  suitable  cases,  it  has  by  no  means  become  the  established  custom  to 
trust  to  it,  and  probably  most  practitioners  have  never  attempted  it, 
even  under  the  most  favorable  conditions.  (The  possibility  of  the 
operation  is  based  ou  the  extreme  mobility  of  the  fa?tus  before  the 
membranes  are  ruptured.^  After  the  watei-s  have  escaped  the  uterine 
walls  embrace  the  foetus  more  or  less  closely,  and  version  can  no  longer 
be  readily  performed  in  this  manner. 

(  It  may  therefore  be  laid  down  as  a  rule  that  it  should  only  be 
attempted  when  the  abnormal  position  of  the  fcetus  is  detected  before 
labor  has  commenced,  or  in  the  early  stage  of  labor,  when  the  mem- 
branes are  unruptured.^  It  is  also  unsuitable  for  any  but  transvei*se 
presentations,  for  it  is  not  meant  to  effect  complete  evolution  of  the 
foetus,  but  only  to  substitute  the  head  for  the  ujiper  extremity.  It  is 
juseless  whenever  rapid  delivery  is  indicated,  for  after  the  head  is 
^.broujrht  over  the  brim  the  conclusion  of  the  case  must  be  left  to  the 
Natural  powers. 

The  manner  of  detecting  the  presentation  by  palpation  has  been 
already  described  (p.  127),  and  the  success  of  the  operation  depends 
on  our  being  able  to  ascertain  the  positions  of  the  head  and  breech 
through  the  uterine  walls.  Should  labor  have  commenced  and  the  os 
be  dilated,  the  transverse  presentation  may  be  also  made  out  by  vaginal 
examination.  Should  the  abnormal  presentation  be  detected  before 
labor  has  actually  begun,  it  is  in  most  cases  easy  enough  to  alter  it  and 
to  bring  the  foetus  into  the  longitudinal  axis  of  the  uterine  cavity. 
Pinard '  recommends  that  after  this  has  been  done  the  fVetus  should  be 
maintained  in  position  by  a  well-fitting  elastic  abdominal  belt.  It  is 
seldom,  however,  discovered  until  labor  has  commenced/and  even  if 
it  be  altered  the  child  is  extremely  apt  to  resume  in  a  short  time  the 
faulty  position  in  which  it  Mas  formerly  lying.  Still,  there  can  be  no 
harm  in  making  the  attemjit,  since  the  operation  itself  is  in  no  way 
painful,  and  is  absolutely  without  risk  eiti)er  to  the  mother  or  child. 
AVhen  the  transverse  presentation  is  detected  early  in  labor,  I  believe 
it  is  good  practice  to  endeavor  to  remedy  it  by  external  manipulation, 
and  if  it  fail  we  may  at  oncie  proceed  to  other  and  more  certain  methods 
of  operating.  The  procedure  itself  is  abundantly  simple.  The  patient 
is  placed  on  her  back,  and  the  position  of  the  foetus  ascertained  by  ])al- 

^  De  la  Version  par  Maneuvres  externes,  Paris,  1878. 


TURNING.  4G7 

pation  as  accurately  as  possible,  in  the  manner  already  described.)  The 
palms  of"  the  hands  being-  then  j)luced  over  the  opposite  poles  of  the 
foetus,  by  a  series  of  gentle  gliding  movements  the  head  is  pushed 
toward  the  pelvic  brim,  while  the  breech  is  moved  in  the  opposite 
direction.  The  facility  with  which  the  foetus  may  sometimes  be 
moved  in  this  way  can  hardly  be  apjn-eciated  by  those  who  have 
never  attempted  the  operation.  As  soon  as  the  change  is  effected  the 
long  diameters  of  the  foetus  and  the  uterus  will  correspond,  and  vaginal 
examination  will  show  that  the  shoulder  is  no  longer  presenting  and  that 
the  head  is  over  the  pelvic  brim.  If  the  os  be  sufficiently  dilated  and 
labor  in  progress,  the  membranes  should  now  be  punctured  and  the 
position  of  the  foetus  maintained  for  a  short  time  by  external  pressure, 
until  we  are  certain  that  the  cephalic  presentation  is  permanently  estab- 
lished. If  labor  be  not  in  progress,  an  attempt  may  at  least  be  made 
to  effect  the  same  object  by  pads  and  a  binder,  one  pad  being  placed  on 
the  side  of  the  uterus  in  the  situation  of  the  breech,  and  another  on  the 
opposite  side  in  the  situation  of  the  head. 

On  account  of  the  difficulty  of  performing  cephalic  version  in  the 
manner  usually  recommended,  it  has  practically  scarcely  been  attempted, 
and  with  the  exception  of  some  more  recent  authors  it  is  generally  con- 
demned by  writers  on  systematic  midwifery.  Still,  the  operation  offers 
unquestionable  advantages  in  those  transverse  presentations  in  which 
rapid  delivery  is  not  necessary,  and  in  which  the  only  object  of  inter- 
ference is  the  rectification  of  malj)Osition ;  for  if  successful  the  child 
is  spared  the  risk  of  being  drawn  footling  through  the  pelvis.  (The 
objections  to  cephalic  version  are  based  entirely  on  the  difficulty  of 
performance^  and,  undoubtedly,  to  introduce  the  hand  within  the 
uterus,  searcn  for,  seize,  and  afterward  place  the  slippery  head  in  the 
brim  of  the  pelvis,  could  not  be  an  easy  process,  even  under  the  most 
favorable  circumstances,  and  must  always  be  attended  with  considerable 
risk  to  the  mother.  Velpeau,  who  strongly  advocated  the  operation, 
was  of  opinion  that  it  might  be  more  easily  accomplished  by  pushing 
up  the  presenting  part  than  by  seizing  and  bringing  down  the  head. 
Wigand  more  distinctly  pointed  out  that  the  head  could  be  brought  to 
a  proper  position  by  external  manipulation,  aided  by  the  fingers  of  one 
hand  within  the  vagina.  Braxton  Hicks  has  laid  down  clear  rules  for 
its  performance,  which  render  cephalic  version  easy  to  accomplish  under 
favorable  conditions,  and  will  doubtless  cause  it  to  become  a  recognized 
mode  of  treating  malpositions.  The  number  of  cases,  however,  in 
which  it  can  be  performed  must  always  be  limited,  since,  as  in  turn- 
ing by  external  manipulation  alone,  it  is  necessary  that  the  liquor 
anniii  should  be  still  retained  or  at  least  have  only  recently  escaped; 
that  the  presentation  be  freely  movable  about  the  pelvic  brim;  and 
that  there  be  no  necessity  for  rapid  delivery.  (J)y.  Hicks  does  not 
believe  protrusion  of  the  arm  to  be  a  contraindication,  and  advises 
that  it  should  be  carefully  replaced  within  the  uterus.  \  When,  how- 
ever, protrusion  of  the  arm  has  occurred,  the  thorax  is  so  constantly 
pushed  down  into  the  pelvis  that  replacement  can  neither  be  safe  nor 
pra(tieable,  except  under  unusually  favorable  conditions,  and  podalic 
version  will  be  necessary. 


4(J.S  OBSTETRW  OPKRA  TIONS. 

Method  of  Performance. — It  is  impossihUi  to  {Icscribc  the  nu'thod 
of  ])L'rl()niiinj;-  i-cjtlialic  vorsion  more  t'onoiscly  and  clearly  than  in  J)r. 
Hieks'  own  words,  "introduce,"  lie  says,  "the  left  hand  into  the 
vagina,  as  in  podalic  version  ;  ])Iace  the  right  hand  on  tiie  outside  of 
the  abdomen,  in  order  to  make  out  the  position  of  the  lu'tus  and  the 
direction  of  its  head  and  feet.  IShould  the  shoulder,  for  instance,  ju'e- 
sent,  then  push  it  with  one  or  two  fingers  in  the  direction  of  the  feet. 
At  the  same  time  pressure  with  the  other  hand  should  be  exerted  on 
the  ce])halic  end  of  the  child.  This  will  bring  the  iiead  down  to  the 
OS ;  then  let  the  head  be  received  on  the  ti})S  of  the  two  inside  fingers. 
The  head  Mill  play  like  a  ball  between  the  two  hands;  it  will  be  under 
their  command,  and  can  be  placed  in  almost  any  part  at  will.  Let  the 
head  then  be  placed  over  the  os|  taking  care  to  rectify  any  tendency  to 
face  presentation.)  It  is  as  well,  if  the  breech  will  not  rise  to  the  fundus 
readily,  after  the  head  is  fairly  in  the  os  to  withdraw  the  hand  from  the 
vagina,  and  with  it  press  up  the  breech  from  the  exterior.  The  hand 
which  is  retaining  gently  the  head  from  the  outside  should  continue 
there  for  some  little  time,  till  the  pains  have  ensured  the  retention  of 
the  child  in  its  new  position  and  the  adaptation  of  the  uterine  walls  to 
its  new  form.  (Should  the  membranes  be  perfect,  it  is  advisable  to 
rujiture  them  as  soon  as  the  head  is  at  the  os  uteri  ^  during  their  flow 
and  after  the  head  will  move  easily  into  its  proper  position." 

The  procedure  thus   described  is  so  simple,  and  would  occupy   so 
short  a  time,  that  there  can  be  no  objection  to  trying  it.     Should  we 
fail  in  our  endeavors,  we  shall  not  be  in  a  worse  position  for  eifecting 
I  delivery  by  podalic  version,  which   can  be  proceeded  with  without 
removing  the  hand  from  the  vagina  or  in  any  way  altering  the  position 
^_^of  the  patient. 
"y^        The  method  of  performing  podalic  version  varies  with  the  nature  of 
fi        each  particular  case.     In  describing  the  operation  it  has  been  usual  to 
b  divide  the  cases  into  those  in  which  the  circumstances  are  favorable  and 

the  necessary  manoeuvres  easily  accomplished,  and  those  in  Avhich  there 
are  likely  to  be  considerable  difficulties  and  increased  risk  to  the  mother. 
This  division  is  eminently  practical)le,  since  nothing  can  be  more  varia- 
ble than  the  circumstances  under  which  version  may  be  required.  Belbre 
describing  the  steps  of  the  operation,  it  may  be  w^ell  to  consider  some 
general  conditions  applicable  to  all  cases  alike. 

In  England  the  ordinary  position  on  the  left  side  is  usually  em- 
ployed. On  the  Continent  and  in  America  the  patient  is  placed 
on  her  back,  with  the  legs  supporfed  by  assistants,  as  in  lithotomy. 
The  former  position  is  jM-eferable,  not  only  as  a  matter  of  custom  and 
as  involving  much  less  fuss  and  exposure  of  the  person,  but  because  it 
admits  of  both  the  operator's  hands  being  more  easily  used  in  concert. 
In  cei-tain  difficult  cases,  when  the  liquor  amnii  has  escaped  and  the 
l)ack  of  the  child  is  turned  toward  the  spine  of  the  mother,  the  dorsal 
decubitus  presents  some  advantages  in  enabling  the  hand  to  pass  more 
readily  over  the  body  of  the  child;  but  such  cases  are  comjiaratively 
rare.  (The  patient  should  be  brought  to  the  side  of  the  bed,  across, 
which  she  should  be  laid,  with  the  hips  projecting  over  and  parallel  to 
the  edge,  the  knees  being  flexed  toward  the  abdomen,  and  separated 


TURNING.  4G0 

from  each  other  by  a  pillow  or  by  an  assistant.  Assistants  should  also 
be  placed  so  as  to  restrain  the  patient  if  necessary,  and  prevent  lier 
involuntarily  startinj^  from  the  operator,  as  this  mi<^ht  not  only  embar- 
rass his  movements,  but  be  the  cause  of  serious  injury. 

The  exhibition  of  aiugsthetics  is  peculiarly  advantageous.  There  is 
nothing  which  tends  to  facilitate  the  steps  of  the  process  so  much  as 
stillness  on  the  part  of  the  patient  and  the  absence  of  strong  uterine 
contraction.  When  the  vagina  is  very  irritable  and  the  uterus  firmly 
contracted  round  the  body  of  the  child,  complete  anaesthesia  may  enable 
us  to  effect  version  when  without  it  we  should  certainly  ftiil. 

The  most  favorable  time  for  operating  is  when  the  os  is  fully  dilated, 
before  or  immediately  after  the  rupture  of  the  membranes  and  the  dis- 
charge of  the  liquor  amnii.  The  advantage  gained  by  operating  before 
the  waters  have  escaped  cannot  be  overstated,  since  we  can  then  make 
the  child  rotate  with  great  facility  in  the  fluid  medium  in  which  it 
floats.  In  the  ordinary  operation,  in  which  the  hand  is  passed  into  the 
uterus,  it  is  essential  to  wait  until  the  os  is  of  sufificient  size  to  admit  of 
its  being  introduced  with  safety.  This  may  generally  be  done  when 
the  OS  is  the  size  of  a  dollar,  especially  if  it  be  soft  and  yielding. 

The  practice  followed  with  regard  to  the  hand  to  be  used  in  turning 
varies  considerably.  Some  accoucheurs  always  employ  the  right  hand, 
others  the  left,  and  some  one  or  other  according  to  the  position  of  the 
child.  In  favor  of  the  right  hand  it  is  said  that  most  practitioners 
have  more  power  with  it,  and  are  able  to  use  it  with  greater  gentleness 
and  delicacy.  In  transverse  presentations,  if  the  abdomen  of  the  child 
be  placed  anteriorly,  the  rigjit  hand  is  said  to  be  the  proper  one  to  use, 
on  account  of  the  greater  facility  with  which  it  can  be  passed  over  the 
front  of  the  child  ;  and  in  difficult  cases  of  this  kind,  when  w^e  are  ope- 
rating with  the  patient  on  her  back,  it  certainly  can  be  employed  with 
more  precision  than  the  left.  In  all  ordinary  cases,  however,  the  left 
hand  can  be  introduced  much  more  easily  in  the  axis  of  the  passages, 
the  back  of  the  hand  adapts  itself  readily  to  the  curve  of  the  sacrum, 
and  even  when  the  child's  abdomen  lies  anteriorly  it  can  be  passed  for- 
ward without  difficulty  so  as  to  seize  the  feet.  These  advantages  are 
sufficient  to  recommend  its  use,  and  very  little  practice  is  required  to 
enable  the  practitioner  to  manipulate  with  it  as  freely  as  with  the  right. 
If,  in  addition,  we  remember  that  the  right  hand  is  required  to  operate 
on  the  foetus  through  the  abdominal  walls — and  this  is  a  point  which 
should  never  be  forgotten — we  shall  have  abundant  reasons  for  laying 
it  down  as  a  rule  that  the  left  hand  should  generally  be  employed. 
Before  passing  the  hand  and  arm  they  should  be  freely  lubricated,  with 
the  exception  of  the  palm,  which  is  left  untouched  to  admit  of  a  firm 
grasp  being  taken  of  the  foetal  limbs.  It  is  also  advisable  to  remove 
the  coat  and  bare  the  arm  as  high  as  the  elbow. 

As  it  should  be  a  cardinal  rule  to  resort  to  the  simplest  procedure 
when  practicable,  it  will  be  well  to  consider  first  the  method  by  com- 
bined external  and  internal  manipulation  without  })assing  the  hand  into 
the  uterus,  and  subsequently  that  which  involves  the  introduction  of 
the  hand. 

Turning-  by  Combined  External  and  Internal  Manipulation. — To 


470 


OBSTETRIC  OPERATIONS. 


Fig.  154. 


/ 


eifect  pmlalio  version  hy  the  (■<)iiil)iii('(l  iiictliod  it  is  an  oi5.sential  prclim- 
iiiarv  to  ascertain  the  sitnation  of"  tlio  lu'tiis  as  accurately  a.<  possible. 
It  will  jicnerally  be  eii-^^y  in  transvei-se  j)resentation  to  make  out  the 
breech  and  head  by  ])alpation,  while  in  head  j)re.sentations  the  fonta- 
nelleswill  show  to  which  side  of  the  pelvis  the  lace  is  turned.  The  left 
liand  is  then  to  be  pas.sed  carefully  into  the  va<;ina,  in  the  axis  of  the 
canal,  to  a  suflicient  extent  to  admit  of  the  fingers  pa.-^sing  freely  into 
the  cervix.  To  eflect  this  it  is  not  always  necessary  to  insert  the  whole 
hand,  three  or  four  fingers  being  generally  sufficient. 

If  the  head  lie  in  the  first  (o.l.a.)  or  fourth  (o.l.p.)  position,  push  it 
upward  and  to  the  left,  while  the  other  hand,  placed  externally  on  the 
abdomen,  depresses  the  breech  toward  the  right  (Fig.  154).     By  this 

means  mc  act  simultaneously  on 
both  extremities  of  the  child's 
body,  and  easily  alter  its  position. 
The  breech  is  pushed  down  gently 
but  firmly  by  gliding  the  hand 
over  the  abdominal  wall.  The 
head  will  now  pass  out  of  reach, 
and  the  shoulders  will  arrive  at 
the  OS  and  will  lie  on  the  tips  of 
the  fingers.  This  is  similarly 
pushed  upward  in  the  same  di- 
rection as  the  head  (Fig.  155),  the 
breech  at  the  same  time  being 
still  further  depressed,  until  the 
kn^c_comes  within  reach  of  the 
fingers,  when  (the  membranes  be- 
ing now  ruptured,  if  still  unbro- 
ken) it  is  seized  and  pulled  d(twii 
through  the  os  (Fig.  156).  Oc- 
casionally the  foot  comes  imme- 
diately over  the  os,  when  it  can 
be  .seized  instead  of  the  knee. 
Vei-sion  may  be  facilitated  by 
changing  the  position  of  the  ex- 
ternal hand  and  pushing  the  head 

First  stage  of  Bipolar  Version  :  Elevation  of  the   upward    from    the    iliaC    fossa,  iu- 
llcad   and  Depression  of  the   Breech.    (After      /      ,       «  ,.       .  ,,  ,, 

Barnes.)  stcad  01    Continuing  the  attempt 

to  depress  the  breech  (Figs.  156 
and  157).  tThcse  manipulations  .should  always  be  carried  on  in  the 
intervals,  and  desisted  from  when  the  ]>ains  come  on ;  and  when  the 
pains  recur  with  great  force  and  frequeiuy  the  advantage  of  chloroform 
will  be  particularly  a]ij)arent.  In  the  second  (o.d.a.)  and  third7t).i),r.) 
positions  the  steps  of  the  operation  should  be  reversed :  the  head  is 
pushed  upward  and  to  the  right,  the  breech  downward  and  to  the  left. 
»u  hen  the  position  cannot  be  made  out  with  certainty,  it  is  well  to 
assume  that  it  is  the  first  (o.l.a.),  since  that  is  the  one  most  frequently 
met  with  ;  and  even  if  it  be  not,  no  great  inconvenience  is  likely  to 
occur.  (   If  the  os  be  not  sufficiently  open  to  admit  of  delivery  being 


TURNING. 


All 


concluded,  the  lower  extremity  can  be  retained  in  its  new  position  with 
one  finger  until  dilatation  is  sufficiently  advanced  or  until  the  uterus 


Fig.  155. 


Second  Stage  of  Bipolar  Version :   Elevation  of  the  Shoulders  and  Depression  of  the  Breech. 

(After  Barnes.) 

has  permanently  adapted  itself  to  the  altered  position  of  the  child ;  either 
of  which  results  will  generally  be  effected  in  a  short  space  of  time. 

In  transverse  presentations  the  same  means  are  to  be  adopted,  the 
shoulder  being  pushed  upward  in  the  direction  of  the  head,  while  the 

Fig.  156. 


Third  Stage  of  Bipolar  Version  :  Seiznre  of  the  Knee  and  Partial  Elevation  of  the  Head. 

(After  Barnes.) 

breech  is  depressed  from  without.  This  is  frequently  sufficient  to  bring 
the  knees  within  reach,  e.'^pecially  if  the  membranes  are  entire,  but  ver- 
sion is  much  facilitated  by  pressing  the  head  upward  from  without, 


472 


OBSTETRIC  OPERA  TIOSS. 


alternately  wit li  depression  of  the  l)reecli.  i.  If  the  liqiior  amnii  has 
escaped,  and  the  uterns  is  Hrinly  contracted  round  tlie  l)odyof  the  child, 
it  will  be  found  impossible  to  ettect  an  alteration  in  its  position  without 
the  introduction  of  the  hand,  and  the  ordinary  method  of  turning  must 
be  cmplovcd.^  The  peculiar  advantage  of  the  combined  process  is,  that 
it  in  nowav  interferes  with  the  latter,  lor  should  it  not  succeed  the  IkukI 
can  be  passed  on  into  the  uterus  without  withdrawal  from  the  vagina 

P'iG.  157. 


Fourth  Stage  of  Bipolar  Version  :  Drawing  Down  of  the  Legs  and  Completion  of  Version. 

(After  Barnes.) 

(provided  the  os  be  sufficiently  dilated),  and  the  feet  or  knees  seized  and 
brought  down. 

Turning  with  the  hand  introduced  into  the  uterus,  provided  the 
waters  have  not  or  have  only  rec-cntly  escaped  and  the  os  be  sufficiently 
dilated,  is  an  operation  generally  performed  with  ease. 

The  first  step,  and  one  of  the  most  important,  is  the  introduction  ot" 
the  hand  and  arm.  The  fingers  having  been  pre&sed  together  in  the 
form  of  a  cone,  the  thumb  lying  between  the  rest  of  the  fingers,  the 
hand,  thus  reduced  to  the  smallest  possible  dimensions,  is  slowly  and 
carefully  pa.s.sed  into  the  vagina,  in  the  axis  of  the  outlet,  in  an  interval 
between  the  pain.s,  and  j)a.«sed  onward  in  the  .<ame  cautious  manner 
and  with  a  semi-rotatory  motion  until  it  lies  entirely  within  the  vagina, 
the  direction  of  introduction  being  gradually  changed  fi'om  the  axis  of 
the  outlet  to  that  of  the.  brim.  If  uterine  contractions  come  on,  the 
hand  should  remain  passive  until  they  are  over.  ^It  should  ever  be 
borne  in  mind  as  one  of  the  fundamental  rules  in  performing  version 
that  we  should  act  only  in  the  absence  of  pains,  and  then  with  the 


TURNING. 


473 


utmost  gentleness,  all  force  and  violent  pushing  being  avoidedy   The: 
hand,  still  in  the  form  of  a  cone,  having  arrived  at  tlie  os,  if  this  be 
sufficiently  dilated,  may  be  passed  through  at  once.     If  the  os  be  not 
quite  open,  but  dilataljlc,  the  points  of  the  fingers  may  be  gently  insin- 
uated, and  occasionally  expanded,  so  as  to  press  it  open  sufficiently  to, 
permit  the  rest  of  the  hand  to  pass.     While  this  is  being  done  the  uterus' 
should  be  steadied  by  the  other  hand  placed  externally  or  by  an  assistant. 
If  the  presentation  should  not  previously  have  been  made  out  with  accu- 
racy, we  can  now  ascertain  how  to  pass  the  hand  onward  so  that  its 
})alniar  surface  may  correspond  with  the  abdomen   of  the  child. 

Rupture  of  the  Membranes. — The  memljranes  should  now  be  rup- 
tured, if  possible,  during  the  absence  of  pain,  so  as  to  prevent  the 
waters  being  forced  out.  The  hand  and  arm  form  a  most  efficient  plug, 
and  the  liquor  amnii  cannot  escape  in  any  quantity.  Some  practition- 
ers recommend  that  before  rupturing  the  membranes  the  hand  should 
be  passed  onward  between  them  and  the  uterine  Avails  until  we  reach 
the  feet.  By  so  doing  we  run  the  risk  of  separating  the  placenta; 
besides,  we  have  to  introduce  the  hand  much  farther  than  may  be  neces- 
sary, since  the  knees  are  often  found  lying  quite  close  to  the  os.  As 
soon  as  the  membranes  are  perforated  the  hand  can  be  passed  on  in 
search  of  the  feet  (Fig.  158).  At  this  stage  of  the  operation  increased 
care  is  necessary  to  avoid  anything 

like  force;    and    should    a    pain  ^ig.  158. 

come  on,  the  hand  must  be  kept 
perfectly  flat  and  still,  and  rather 
pressed  on  the  body  of  the  child 
than  on  the  uterus.  If  the  pains 
be  strong,  much  inconvenience 
may  be  felt  from  the  compres- 
sion ;  and  were  the  onward  move- 
ment continued,  or  the  hand  even 
kept  bent  in  the  conical  form  in 
which  it  was  introduced,  rupture 
of  the  uterine  Avails  might  easily 
Ije  caused.  This  is  not  likely  to 
occur  in  the  class  of  cases  now 
under  consideration,  for  it  is 
chiefly  w4ien  the  waters  have  long 
escaped  that  the  progress  of  the 
hand  is  a  matter  of  difficulty. 
Valuable  assistance  may  now  be 
given  by  pressing  the  breech 
downward  from  Avithout,  so  as 
to  bring  the  knees  or  feet  more 
easily  within  the  reach  of  the  in- 
ternal hand.  Having  arrived  at 
the  knees  or  feet,  they  may  be 
seized  l)etM'een  the  fingers  and 
drawn  downward  in  the  absence 
of  a  pain  (Fig.  159).     This  will  cause  the  ftetus  to  revolve  on  its  axis, 


Seizure  of  the  Feet  when  the  Hand 
into  the  Uterus. 


Introduced 


474 


OBSTETRIC  OPERA  TIONS. 


the  breech  will  descend,  and  at  tlie  same  time  the  ascent  of  the  head 
may  be  assisted  by  the  lijiht  hand  from  without.     It  is  a  fjuestion  with 

many  accoucheurs  which   ])art  of 
fi^'-  159-  the  inferior  extremities  should  be 

seized  and  broutrht  down.  Some 
recfjmmend  us  to  seize  l)oth  feet, 
others  ])refer  one  only,  m  hile  some 
advise  the  seizure  of  one  <jr  both 
knees.  In  a  simple  case  of  turn- 
\u^  before  the  escaj)e  of  the  waters 
it  does  not  matter  much  which  (tf 
these  plans  is  followed,  since  ver- 
sion is  accomi)lished  with  the 
greatest  ease  by  any  one  of  them. 
Ilie  seizure  of  the  knee,  however, 
instead  of  the  feet,  offer's  certain 
advantages  which  should  not  be 
overlooked.  It  is  generally  more 
accessible,  affords  a  better  hold 
(the  fingers  being  inserted  in  the 
flexure  of  the  ham),  and,  being 
nearer  the  spine,  traction  acts 
more  directly  on  the  body  of  the 
child.  Any  danger  of  mistaking 
the  knee  for  the  elbow  may  be 
obviated  by  remembering  the  sim- 
ple rule  that  the  salient  angle  of 
the  former,  w'hen  the  thigh  is 
flexed,  looks  toward  the  head  of 
the  child,  of  the  latter  toward  its 
feet.  Certain  advantages  may  also 
be  gained  by  bringing  down  one  foot  or  knee  only,  instead  of  l)oth. 
When  one  inferior  extremity  remains  flexed  on  the  body  of  the  child, 
the  part  which  has  to  pass  through  the  os  is  larger  than  when  both  legs 
are  drawn  down,  and  consequently  the  os  is  more  perfectly  dilated,  and 
less  difficulty  is  likely  to  be  experienced  in  the  delivery  of  the  rest  of 
body,  so  that  the  risk  to  the  child  is  materially  diminished, 
impson,  whose  views  have  been  adopted  by  Barnes  and  other 
writers,  recommends  the  seizing,  if  possible,  in  arm  presentations  of  the 
knee  farthest  from  and  opposite  to  the  presenting  arm,  as  by  this  means 
the  body  is  turned  round  on  its  longitudinal  axis,  and  the  presenting 
arm  and  shoulder  are  more  easily  withdrawn  from  the  os. )  I)r.  Gala-* 
bin  has  carefully  investigated  this  point  in  a  recent  paper,'  and  conw 
tends  that  there  is  a  greater  mechanical  advantage  in  seizing  the  leff 
Mhich  is  nearest  to,  and  on  the  same  side  as,  the  presenting  arm  ;  and 
this,  moreover,  is  generally  more  readily  done.       \ 

As  soon  as  the  head  has  reached  the  fundus  andahe  lower  extremity 
is  brought  through  the  os,  the  case  is  converted  into  a  foot  or  knee  ]>res- 
eutation,  and  it  comes  to  be  a  question  whether  delivery  should  now  be 

1  Ob.-^t.  Trans.,  for  1877,  vol.  xix.  p.  239. 


Drawing  Down  of  the  Feet  and  Completion  of 
Version. 


the  I 
VSii 


TURNING. 


Alb 


left  to  nature  or  terminated  by  art.  Tliis  niust  depend  to  a  certain 
extent  on  the  case  itself  and  on  the  cause  which  necessitated  version, 
but  generally  it  will  be  advisable  to  finish  delivery  without  unnecessary 
delay.  To  accomplish  this,  downward  traction  is  made  during  the 
pains  and  desisted  from  in  the  intervals  (Fig.  160).  As  the  umbilical 
cord  appears,  a   loop   should  be 

drawn  down ;  and  if  the   hands  Fif4.  160. 

be  above  the  head  they  nnist  be 
disengaged  and  brought  over  the 
face,  in  the  same  manner  as  in  an 
ordinary  footling  presentation. 
The  management  of  the  head 
after  it  descends  into  the  cavity 
of  the  pelvis  must  also  be  con- 
ducted as  in  labors  of  that  descrip- 
tion. 

Turning  in  Placenta  Praevia. 
— In  cases  of  placenta  prsevia 
the  OS  will,  as  a  rule,  be  more, 
easily  dilatable  than  in  trans-' 
verse  presentations.  Hicks' 
method  offers  the  great  advan- 
tage of  enabling  us  to  perform 
version  much  sooner  than  was 
formerly  possible,  since  it  only 
requires  the  introduction  of  one 
or  two  fingers  into  the  os  uteri. 
Sliould  we  not  succeed  by  it,  and 
the  state  of  the  patient  indicates 
that  delivery  is  necessary,  we 
have  at  our  command  in  the  fluid 
dilators  a  means  of  artificially 
dilating  the  os  uteri  which  can  , 
be  employed  with  ease  and  safety.  V  If  we  have  to  do  with  a  case  of 
entire  placental  presentation,  the  hand  should  be  passed  at  that  point 
where  the  placenta  seems  to  be  least  attached.)  This  will  always  be 
better  than  attempting  to  perforate  its  substance — a  measure  sometimes 
recommended,  but  more  easily  performed  in  theory  than  in  practice. 
If  the  placenta  only  partially  present,  the  hand  should  of  course  be 
inserted  at  its  free  border.  It  will  frequently  be  advisable  not  to  hasten 
delivery  after  the  feet  have  been  brought  through  the  os,  for  they  form 
of  tliemselves  a  very  efficient  plug,  and  effectually  prevent  further  loss 
of  blood;  while  if  the  patient  be  much  exhausted  she  may  have  her 
strength  recruited  by  stimulants,  etc.  before  the  completion  of  delivery. 

Turning  in  Abdomino-anterior  Positions. — In  abdomino-anterior 
positions,  in  which  the  waters  have  escaped,  and  in  which,  therefore, 
some  difficultv  may  be  reasonably  anticipated,  the  operation  is  gener- 
ally more  easily  performed  with  the  patient  on  her  back  :  the  rjo;ht 
hand  is  then  introduced  into  the  uterus,  and  the  left  employed  exter- 
nally  (Fig.   161).     In  this  way  the  internal  hand  has  to  be  passed  a 


Showing  the  Completion  of  Version. 
(After  Barnes.) 


476 


OBSTETRIC  OPh-RATIOXS. 


shorter  (listiiiK'c  :iii<l   in  a  loss  constrained   position.       The  operator  tin  ii 
'sits  in  front  of  the  ])atient,  m  ho  is  siii)portc'(l  at    the  ed«>;o  of  the  hod  in 


Fi«. 161. 


Showing  the  Use  of  the  Right  Hand  in  Abdomino-anterior  Position. 

the  lithotomy  position  with  the  thighs  ^separated,  and  the  right  hand  is 
passed  np  behind  the  pubes  and  over  the  abdomen  of  the  child. 

DiflBcult  Cases  of  Arm  Presentation. — The  difficulties  of  turning 
culminate  in  those  unfavorable  cases  of  arm  ])resentation  in  which  the 
membranes  have  been  long  ruptured,  the  shoulder  and  arm  pressed 
down  into  the  pelvis,  and  the  uterus  contracted  round  the  body  of  the 
child.  The  uterus  being  firmly  and  spasmodically  contracted,  the 
attempt  to  introduce  the  hand  often  only  makes  matters  worse  by  indu- 
cing more  frequent  and  stronger  pains.  Even  if  the  hand  and  arm  be 
successfully  passed,  much  difticulty  is  often  experienced  in  causing  the 
body  of  the  child  to  rotate;  for  we  have  no  longer  the  fluid  medium 
present  in  which  it  floated  and  moved  with  ease,  and  the  arm  of  the 
operator  may  be  so  cramped  and  pained  by  the  pressure  of  the  uterine 
walls  as  to  be  rendered  almost  powerless.  The  risk  of  laceration  is 
also  greatly  increased,  and  the  care  necessary  to  avoid  so  serious  an  acci- 
dent adds  much  to  the  difficulty  of  the  ojieratiou. 

Value  of  Anaesthesia  in  Relaxing-  the  Uterus. — In  these  perplex- 
ing cases  various  ex]>cdients  have  been  tried  to  cause  relaxation  of  the 
spasmodically  contracted  uterine  fibres,  such  as  copious  venesection  in 
the  erect  attitude  until  fainting  is  induced,  M'arm  baths,  tartar  emetic, 
and  similar  depressing  agents.  None  of  these,  however,  are  so  useful 
as  the  free  administration  of  chloroform,  which  has  practically  super- 
seded them  all,  and  often  answers  most  effect ually  when  given  to  its 
full  surgical  extent. 

The  hand  nuist  be  introduced  with  the  precautions  already  described. 


TURNING.  477 

If  the  arm  be  completely  protruded  into  the  vagina,  we  should  pass  the 
hand  along  it  as  a  guide,  and  its  palmar  surface  will  at  once  indicate 
the  position  of  the  child's  abdomen.  No  advantage  is  gained  by 
amputation,  as  is  sometimes  recommended.  When  the  os  is  reached 
the  real  difficulties  of  the  operation  commence,  and  if  the  shoulder  be 
firmly  pressed  down  into  the  brim  of  the  pelvis  it  may  not  be  easy  to 
insinuate  the  hand  past  it.  It  is  allowable  to  repress  the  presenting 
part  a  little,  but  with  extreme  caution,  for  fear  of  injuring  the  con- 
tracted uterine  parietes.  Herman  Mias  pointed  out  that  in  some  cases 
the  difficulty  is  increased  by  the  shoulder  of  the  prolapsed  arm  being 
caught  beneath  the  contraction-ring  (Bandl's),  and  he  advises  that  it 
should  be  released  by  pressing  it  toward  the  centre  of  the  cervical 
canal.  It  is  better  to  insinuate  the  hand  past  the  obstruction,  which 
can  generally  be  done  by  patient  and  cautious  endeavors.  Having 
succeeded  in  passing  the  shoulder,  the  hand  is  to  be  pressed  forward 
in  the  intervals,  being  kept  perfectly  flat  and  still  on  the  body  of  the 
foetus  when  the  pains  come  on.  It  is  much  safer  to  press  on  it  than 
on  the  uterine  walls,  which  might  readily  be  lacerated  by  the  project- 
ing knuckles.  When  the  hand  has  advanced  sufficiently  far,  it  will  be 
better,  for  the  reasons  already  mentioned,  to  seize  and  bring  down  one 
knee   only. 

"When  the  Foot  is  brought  Down,  but  the  Foetus  -will  not 
Revolve. — Even  when  the  foot  has  been  seized  and  In'ought  through 
the  OS,  it  is  by  no  means  always  easy  to  make  the  child  revolve  on  its 
axis,  as  the  shoulder  is  often  so  firmly  fixed  in  the  pelvic  brim  as  not 
to  rise  toward  the  fundus.  (Some  assistance  may  be  derived  from  push- 
ing the  head  upward  from  without,  which  of  course  would  raise  the 
shoulder  along  with  it./  If  this  should  fail,  we  may  effect  our  object 
by  passing  a  noose  of  tape,  or  wire  ribhoP..  round  the  limb,  by  which 
traction  is  made  downward  and  backward  ;  at  the  same  time  the  other 
hand  is  passed  into  the  vagina  to  displace  the  shoulder  and  push  it  out 
of  the  brim.  It  is  evident  that  this  cannot  be  done  as  long  as  the  limb 
is  held  by  the  left  hand,  as  there  is  no  room  for  both  hands  to  pass  into 
the  vagina  at  the  same  time.  By  this  manoeuvre  version  may  be  often 
completed  when  the  foetus  cannot  be  turned  in  the  ordinary  way. 
Various  instruments  have  been  invented  both  for  passing  a  fillet  round 
the  child's  limb  and  for  repressing  the  shoulder,  but  none  of  them 
can  compete,  either  in  facility  of  use  or  safety,  with  the  hand  of  the 
accoucheur. 

When  Mutilation  is  Necessary. — Should  all  attempts  at  version 
fail,  no  resource  is  left  but  the  mutilation  of  the  child,  either  by  evis- 
ceration or  decapitation.  This  extreme  measure  is,  fortunately,  sel- 
dom necessary,  as  with  due  care  version  may  generally  be  eifected, 
even  under  the  most  unfavorable  circumstances. 

^  "  Note  on  One  of  the  Causes  of  Difficulty  in  Turning,"  Obst.  Trcuis.,  for  18S(i,  vol. 
xxviii.  p.  150. 


478  OBSTE'IRIC  OPERATIONS. 


CHAPTER   III. 

THE  FORCEPS. 

Use  of  the  Forceps  in  Modern  Practice. — Of  all  ol)stetric  o]-)era- 
tions,  the  most  important,  because  the  most  truly  conservative,  both  to 
the  mother  and  child,  is  the  application  of  the  forceps.  In  m<idern 
midwifery  the  use  of  the  instrument  is  much  extended,  and  it  is  now 
applied  by  some  of  our  most  experienced  accoucheurs  with  a  frecpiency 
which  older  practitioners  would  have  strongly  reprobated.  That  the 
injudicious  and  unskilful  use  of  the  forceps  is  capal^le  of  doing  much 
harm  no  one  will  for  a  moment  deny.  This,  however,  is  not  a  reason 
for  rejecting  the  recommendation  of  those  who  advise  a  more  frequent 
resort  to  the  operation,  but  rather  for  urging  on  the  practitioner  the 
necessity  of  carefully  studying  the  manner  of  performing  it,  and  of 
making  himself  familiar  with  the  ca.ses  in  which  it  is  easy  or  the 
reverse.  Nothing  but  practice — at  first  on  the  dummy,  and  afterward 
in  actual  cases — can  impart  the  ojierative  dexterity  which  it  should  be 
the  aim  of  every  obstetrician  to  acquire,  and  without  Avhich  there  can 
be  no  assurance  of  his  doing  his  duty  to  his  patient  efficiently. 

Description. — i-The  forceps  may  best  be  described  as  a  pair  of  artificial 
hands  by  which  the  foetal  head  may  be  grasped  and  drawn  through  the 
maternal  pas'sages  by  a  vh  a  fronfe  when  the  vis  a  tergo  is  deficient^ 
This  description  will  impress  on  the  mind  the  important  action  of  the 
instrument  as  a  tractor,  to  which  all  its  i)0wers  are  subservient.  The 
forceps  consists  of  two  separate  blades  of  a  curved  form  adapted  to  fit 
the  child's  head ;  a  lock  by  which  the  blades  are  united  after  introduc- 
tion ;  and  handles  w^hich  are  grasped  by  the  operator  and  by  means  of 
which  traction  is  made.  It  would  be  a  wearisome  and  unsatisfactory 
task  to  dwell  on  all  the  modifications  of  the  instrument  which  have 
been  made,  which  are  so  numerous  as  to  make  it  almost  appear  as  if 
no  one  could  practice  midwifery  with  the  least  pretension  to  eminence 
unless  he  has  attached  his  name  to  a  new  variety  of  forceps. 

The  Short  Forceps. — The  original  instrument,  invented  by  the 
Cham])erlens,  may  ])e  looked  uj)on  as  the  type  of  the  short  straight 
force[)S,  M"hich  has  been  more  employed  than  any  other,  and  which, 
perhaps,  finds  its  best  representative  in  the  short  forceps  of  Denman 
(Fig.  162).  Indeed,  the  only  essential  difference  between  the  two  is 
the  lock  of  the  latter,  originally  invented  by  Smellie,  which  is  so  excel- 
lent that  it  has  been  ado})ted  in  all  British  forceps,  and  which  for  facility 
of  juncture  is  much  superior  to  either  the  French  pivot  or  the  German 
lock,  Avhile  for  firmness  it  is,  for  all  })ractical  purj)<)ses,  as  good  as  either. 
In  this  instrument  the  blades  are  7,  the  handle  4^  inches  in  length  ;  the 
extremities  of  the  blades  are  exactly  one  inch  ajiart,  and  the  space 
between  them  at  their  widest  part  is  2|  inches.     The  blades  measure 


THE  FORCEPS. 


479 


1^  inches  at  their  greatest  breadth,  and  sj^ring  with  a  regular  sweep 
directly  from  the  lock,  there  being  no  shank.  The  blades  are  formed 
of  the' best  and  most  highly  tempered  steel  to  resist  the  strain  to  which 
they  are  occasionally  subjected,  and  they  are  smooth  and  rounded  on 
their  inner  surface  to  obviate  the  risk  of  injury  to  the  scalp  of  the 
child. 

The  special  advantages  claimed  for  this  form  of  instrument  is  that, 
the   two   halves   being   precisely  similar,    no   care   or   forethought    is 

Fig.  162. 


O 


Denman's  Short  Forceps. 

required  on  the  part  of  the  practitioner  as  to  which  blade  should  be 
introduced  uppermost — au  advantage  of  no  great  value,  since  no  one 
should  undertake  a  case  of  forceps  delivery  who  has  not  sufficient  know- 
ledge of  the  operation  and  presence  of  mind  enough  to  obviate  any  risk 
from  the  introduction  of  the  wrong  blade  first.  On  account  of  its 
shortness  and  the  want  of  the  second  or  pelvic  curve  it  is  only  adapted 
for  cases  in  which  the  head  is  low  down  in  the  pelvis  or  actually  rest- 
ing on  the  perineum. 

The  Pelvic  Curve. — The  question  of  the  second  or  pelvic  curve  is 
one  on  which  there  is  much  diiference  of  opinion.  The  forceps  we  are 
now  considering  (and  the  mauy  modifications  formed  on  the  same  plan) 
is  constructed  solely  with  reference  to  its  grasp  on  the  child's  head,  and 
without  regard  to  the  axes  of  the  maternal  passages.  Consequently, 
were  Me  to  introduce  it  wdien  the  head  was  at  the  upper  part  of  the 
pelvis,  we  could  not  fail  to  expose  the  soft  parts  to  the  risk  of  contusion, 


480  OBSTETRIC  OPERATIONS. 

aud  (in  consequence  of  tlio  necessity  of  drawing  more  directly  backward) 
nndnly  stretcli  and  even  lacerate  the  perineum.  Hence  it  is  now 
admitted  by  obstetricians,  with  few  exce})tions,  that  the  second  curve  is 
essential  before  the  complete  descent  of  the  head,  although  it  is  not  ab- 
solutely so  after  this  has  taken  place.  The  only  circumstances  under 
which  a  straight  blade  can  possess  any  suj)eriority  are  in  certain  cases 
of  occipito-posterior  position  in  which  it  is  found  necessary  to  I'otate  the 
head  round  a  large  extent  of  the  pelvis,  when  the  circular  sweep  of  a 
strongly  curved  instrument  might  prove  injurious.  Such  cases,  how- 
ever, are  of  rare  occurrence,  and  need  in  no  way  influence  the  general 
employment  of  the  pelvic  curve. 

Zeigler's  Forceps. — The  short  forceps  usually  employed  in  Scotland 
is  the  invention  of  the  late  Dr.  Zeigler  (Fig.  163),  and  is  useful  from 
the  facility  with  which  the  blades  may  be  introduced  in  accurate  apposi- 
tion to  each  other — a  point  which  in  practice  is  of  no  little  value.  In 
general  size  and  appearance  it  closely  resembles  Deuman's  forceps,  but 
the  fenestra  of  the  lower  blade  is  continued  down  to  the  handle.  In 
introducing,  the  lower  blade  is  slipped  over  the  handle  of  the  other 
blade,  already  in  situ,  and  thus  it  is  guided  with  great 
Fig.  163.  certainty  into  a  proper  position,   locking  itself  as  it 

passes  on.  This  instrument  has  the  disadvantage  of 
not  having  the  second  curve,  but  the  facility  of  intro- 
duction has  rendered  it  a  great  favorite  with  many 
who  have  been  in  the  habit  of  employing  it. 

The  Long  Forceps. — For  cases  in  which  the  head 
is  not  on  the  perineum,  or  at  least  not  quite  low  in 
the  pelvis,  a  longer  instrument  is  essential.  To  meet 
this  indication  Smellie  invented  the  long  forceps, 
which,  like  the  shorter  instrument,  has  been  very 
variously  modified.  (  The  most  perfect  instrument  of 
the  kind  employed  in  Great  Britain  is  that  known  as 
Simpson's  forceps  (Fig.  164),  which  combines  many 
excellent  points  selected  from  the  forceps  of  various 
obstetricians,  as  well  as  some  original  additions,  and 
which,  as  a  whole,  has  never  been  surpassed  until 
Zeigler's  Forceps.  Tarnier's  or  its  modification  was  invented.  The 
curved  portions  of  the  blades  are  6J  inches  long,  the 
fenestra  measuring  1^  in  its  widest  part.  The  extremities  of  the  blades 
are  1  inch  asunder  when  the  haudles  are  closed,  and  three  inches  at 
their  widest  part.  The  object  of  this  somewhat  unusual  width  is  to 
lessen  the  compressing  power  of  the  instrument,  without  in  any  way 
interfering  with  its  action  as  a  tractor.  The  j^elvic  curve  is  less  than 
in  most  long  forceps,  so  as  to  admit  of  the  rotation  of  the  head  when 
necessary  without  the  risk  of  injuring  the  maternal  structure.  Between 
the  curve  of  the  blade  and  the  lock  is  a  straight  portion  or  shank 
measuring  2f  inches,  which  before  joining  the  handle  is  bent  at  right 
angles  into  a  knee.  This  shank  is  a  useful  addition  to  all  forceps,  and 
is  essential  in  the  long  forceps  to  ensure  the  junction  of  the  blades 
beyond  the  parts  of  the  mother,  Mhich  might  otherwise  be  caught  in 
the  lock  and  injured.     The  knees  serve  the  purpose  of  preventing  the 


THE  FORCEPS. 


481 


Fig.  164. 


e 


blades  from  slipping  from  each  other  after  they  have  been  united. 
They  also  admit  of  one  finger  being  introduced  above  the  lock  and 
used  as  an  aid  in  traction — a  pro- 
vision which  is  made  in  some  other 
varieties  of  long  forceps  by  a  semi- 
circular bend  in  each  shank.  The 
handles,  which  in  most  British  for- 
ceps are  too  small  and  smooth  to 
afford  a  firm  grasp,  are  serrated  at 
the  edge,  and  flattened  from  before 
backward,  so  as  to  fit  the  closed  fist 
more  accurately.  At  their  extremi- 
ties, near  the  lock,  there  are  a  pair  of 
projecting  rests,  over  which  the  fore 
and  middle  fingers  may  be  passed  in 
traction,  and  which  greatly  increase 
our  power  over  the  instrument.  Al- 
though this  and  other  varieties  of  the 
long  forceps  are  specially  constructed 
for  application  when  the  head  is  high 
in  the  pelvis,  it  answers  quite  as  well 
as  the  short  forceps — indeed  in  most 
respects  better — when  the  head  has 
descended  low  down.  It  is  a 
decided  advantage  for  the  practi- 
tioner to  habituate  himself  to  the 
use  of  one  instrument,  with  the  ap- 
plication and  power  of  which  he 
becomes  thoroughly  familiar.  It  is 
a  mere  waste  of  space  and  money 
for  him  to  encumber  himself  with  a 
number  of  instruments  of  various  shapes  and  sizes,  and  he  may  be  sure 
that  a  good  pair  of  long  forceps  will  be  suitable  for  every  emergency 
and  in  any  position  of  the  head. 

CThe  chief  argument  against  the  use  of  such  an  instrument  in  simple 
cases  is  its  great  power./  This,  however,  is  entirely  based  on  a  miscon- 
ception. The  existence  of  power  does  not  involve  its  use,  and  the 
stronger  instrument  can  be  employed  with  quite  as  much  delicacy  and 
gentleness  as  the  weaker.  The  remarks  of  Dr.  Hodge  ^  on  this  point 
are  extremely  apposite,  and  are  well  worthy  of  quotation.  He  says : 
"  Certainly  no  man  ought  to  apply  the  forceps  who  has  not  sufficient 
discretion  to  use  no  more  force  than  is  absolutely  requisite  for  safe 
delivery.  If,  therefore,  there  is  more  power  at  command,  he  is  not 
obliged  to  use  it ;  while,  on  the  contrary,  if  much  power  be  demanded,, 
he  can,  within  the  bounds  of  prudence,  exercise  it  by  the  long  forceps,, 
but  with  the  short  forceps  his  efforts  might  be  unavailing.  Moreover,, 
in  cases  of  difficulty,  the  short  forceps  being  used,  the  practitioner 
would  be  forced  to  make  great  muscular  efforts,  while  with  the  long 
forceps,  owing  to  the  great  leverage,  such  effort  Avill  be  comparatively 


Simpson's  Forceps. 


31 


^  System  of  Obstetrics,  p.  242. 


482 


OBSTETRIC  OPERATIONS. 


Fig.  165. 


triHinj.^,  and  of  course  the  whole  loree  demaiuled  can  Ix-  much  more 
delicately,  and  at  the  same  time  efficiently,  applied,  and  witii  more  safety 
to  the  tissues  of  the  child  and  its  parent." 

Continental  Forceps. — The  forceps  usually  employed  on  the  Con- 
tinent and  in  America  differs  considerably,  both  in  appearance  and  cou- 
.struction,  from  that  in  use  in  Great  Jiritain.  As  a  rule,  it  is  a  larger 
and  more  powerful  instrument,  joined  by  a  pivot  or  button  joint,  and 
it  always  possesses  the  second  or  pelvic  curve.  Of  late  years  Simp- 
son's forceps  has  been  much  employed  in  some  parts  of  Germany.  The 
chief  objection  to  the  continental  instruments  is  their  cumbrousness.  This 
is  chiefly  in  the  handles,  which  in  many  of  them  are  forged  in  a  piece 
Avith  the  blades,  the  part  introduced  within  the  maternal  structures  not 
being  materially  different  from  the  corresponding  part  of  the  English 
instrument. 

Tarnier's  Forceps. — The  forceps  invented  by  Professor  Tarnier 
(Fig.  165)  has  recently  attracted  considerable  attention.  In  this  instru- 
ment traction  is  not  made  on  the  han- 
dles by  Avhich  the  blades  are  introduced, 
as  in  ordinary  forceps,  but  on  a  supple- 
mentary handle  (ft)  subsequently  attached 
to  the  blades  near  the  lower  opening  of 
their  fenestrae  (6).  The  object  claimed 
for  this  arrangement  is  that  less  force  is 
required  in  traction,  which  can  always 
be  made  in  the  proper  axis  of  the  j^elvis, 
that  the  blades  are  not  likely  to  slip,  and 
that  rotation  of  the  head  is  not  interfered 
with.  The  handles  of  the  forceps,  more- 
over, guide  the  operator  to  the  direction 
in  which  he  ought  to  pull,  since  all  that 
is  required  is  to  keep  the  traction-rods 
parallel  to  them.  This  instrument,  how'- 
ever,  although  theoretically  perfect,  is 
somewhat  too  complicated  for  general 
use. 

Simpson's  Axis-traction  Forceps. 
— Professor  Simpson  of  Edinburgh  has  invented  a  modification  of 
Tarnier's  instrument,  which  he  calls  the  "  Axis-traction  forceps  "  (Fig. 
166).  The  supplementary  handles  are  fixed  to  the  blades,  and  the 
whole  mechanism  is  much  simj^ler  than  in  Tarnier's  forceps.  Dr.  Simp- 
son reports  very  favorably  of  this  forceps,  and  it  is  certainly  well  adajited 
for  the  object  aimed  at.  For  .some  years  I  have  used  it  extensively, 
and  have  every  reason  to  be  satisfied  with  it,  especially  in  the  high-for- 
ceps operation,  in  which  it  seems  to  me  superior  to  any  other  instru- 
ment. 

Action  of  the  Instrument. — The  forceps  is  generally  said  to  act  in 
three  different  ways : 
1st.  As  a  tractor. 
2d.  As  a  levei\ 
3d.  As  a  compressor. 


Tarnier's  Forceps. 


THE  FORCEPS. 


483 


Ficj.  166. 


It  is  more  especially  as  a  tractor  that  the  instrument  is  of  value,  and 
it  is  used  with  the  greatest  acTvautage  wlien  it  is  employed  merely  to 
supplement  the  action  of  the  uterus,  which  is  insufficient  of  itself  to 
effect  delivery,  or  when,  from  some  com- 
plication, it  is  necessary  to  complete  labor 
with  grc'ater  rapidity  than  can  be  accom- 
])lished  by  the~uuaided  powers  of  nature. 
J  n  most  cases  traction  alone  is  sufficient ; 
but  in  order  that  it  may  act  satisfac- 
torily, and  that  the  instrument  may  not 
slip,  a  proper  construction  of  the  forceps 
and  a  sufficient  curvature  of  the  blades 
are  essential.  The  want  of  these  is  the 
radical  fault  of  many  of  the  short,  straight 
instriunents  in  common  use,  which  have 
a  tendency  to  slip  during  our  effi^rts  at 
extraction. 

The  forceps  acts  also  as  a  Igy^r,  but 
this  action  has  been  greatly  exaggerated. 
It  is  generally  described  as  a  lever  of 
the  first  class,\the  power  being  at  the 
handles,  the  fulcrum  at  the  lock,  and 
the  weight  at  the  extremities.  There 
may  possibly  be  some  leverage  power 
of  this  kind  when  the  instrument  is 
first  introduced  and  the  handles  held 
so  loosely  that  one  blade  is  able  to  work 
on  the  other.  But  as  ordinarily  used  the  handles  are  held  with  a  suf- 
ficiently firm  grasp  to  prevent  this  movement,  and  then  the  two  blades 
practically  form  a  single  instrument. 

Galabin,  who  has  studied  this  subject  in  detail,  points  out^  that  "  1. 
The  lever  is  formed  by  both  blades  of  the  forceps  and  the  foetal  head 
united  in  one  immovable  mass.  As  soon  as  the  blades  begin  to  slip 
over  the  head  the  lever  is  decomposed,  and  the  SM^aying  movement 
ceases  to  have  any  mechanical  advantage.  2.  (The  power  is  applied  to 
the  handles  in  a  slanting  direction. )  The  resistance  or  Aveight  does  not 
act  at  a  point  either  between  the  former  and  the  fulcrum  or  beyond  the 
fulcrum,  but  at  a  point  in  a  plane  nearly  at  right  angles  to  the  line  join- 
ing these  two  points,  and  its  direction  is  a  line  perpendicular  to  that 
plane  of  the  pelvis  in  which  the  greatest  section  of  the  head  is 
engaged ;  that  is  to  say,  in  the  case  of  straight  forceps,  nearly  parallel 
to  the  handles.  The  lever  formed  does  not,  therefore,  strictly  speak- 
ing, belong  to  any  one  of  the  three  orders  into  which  levers  are  com- 
monly divided.  3.  The  fuknun  is  fixed  partly  by  friction,  partly  by 
the  combination  of  traction  "with  oscillatory  movements — in  other 
words,  by  the  power  being  directed  in  great  measure  downward  and 
only  slightly  to  one  side." 

He  further  shows  that  the  pendulum  motion  of  the  forceps  is  super- 

^  Galabin,  "  Action  of  Midwifery  Forceps  as  a  Lever,"  Obstetrical  Journal,  Novem- 
ber, 1876. 


Simpson's  Axis-Traction  Forceps. 
C,  b.  Traction  handle.     c,f.  Line  of  traction. 


484  OBSTETRIC  OPERATIONS. 

fliidus  ill  all  oidiiiarv  forcej^s  operations,  in  wliic-h  traction  alone  is  amply 
siilKc'ient  ior  ck'livciy ;  but  that  when  the  liead  is  inij)acte(l  and  ^^reat 
force  is  required  for  its  extraction  a  nieclianical  advantage  may  he  gained 
from  having  recourse  to  an  oscillatory  movement,  which  should,  how- 
ever, be  very  limited,  and  only  continued  if  founil  to  effect  distinct 
advance  of  the  head. 

Regarding  the  compressive  power  of  the  instrument  there  has  been 
much  ditlerence  of  opinion.  There  is  no  doubt  that  the  forceps, 
especially  some  of  the  foreign  instruments  in  Avhich  the  points  nearly 
approach  each  other,  is  capable  of  exerting  considerable  compression  on 
the  head.  It  is,  however,  extremely  problematical  if  this  action  be  of 
I  real  value.  It  is  to  be  borne  in  mind  that  in  cases  of  protracted  labor 
I  the  head  has  been  already  moulded  and  compressed,  and  the  bones  have 
I  been  made  to  overlap  each  other  to  their  utmost  extent,  by  the  sides  of 
the  pelvis.  AVe  can  scarely,  therefore,  expect  to  diminish  the  head  much 
more  by  the  forceps  without  employing  an  amount  of  force  that  will 
seriously  endanger  the  life  of  the  child.)  It  is  in  cases  of  disprojiortion 
between  the  head  and  the  pelvis,  depending  on  slight  antero-posterior 
contraction  of  the  pelvic  brim,  that  diminution  of  the  child's  head  by 
compression  would  be  most  useful.  Then,  however,  the  pressure  of  the 
forceps  is  exerted  on  that  portion  of  the  head  which  lies  in  the  most 
roomy  diameter  of  the  pelvis,  where  there  is  no  want  of  si)ace.  If 
this  pressure  do  not  increase  the  opposite  diameter,  which  is  in  apposi- 
tion to  the  narrower  portion  of  the  pelvis,  it  can  at  least  do  nothing 
toward  lessening  it,  and  diminution  of  any  other  part  of  the  child's 
head  is  not  required. 

Dynamical  Action  of  the  Forceps. — The  mere  introduction  of  the 
I  forceps  sometimes  excites  increased  uterine  action,  ITirough  the  reflex 
1  irritation  induced  by  the  presence  of  a  foreign  body  in  the  vagina, 
j  This  has  been  called  the  dynamical  action  of  the  forceps,  but  it  cannot 
!  be  looked  upon  in  any  other  light  than  that  of  an  occasional  accidental 
:  result. 

The  circumstances  indicating  the  use  of  the  forceps  have  been  sepa- 
rately considered  elsewhere,  and  to  recapitulate  them  here  -would  only 
lead  to  needless  repetition.  I  shall  therefore  now  merely  describe  the 
mode  of  using  the  instrument. 

Before  doing  so  it  is  well  to  repeat  what  has  already  been  said  as  to 
the  difference  between  what  may  be  termed  the  high  and  low  forceps 
operations.  The  application  of  the  instrument  when  the  head  is  low 
in  the  pelvis  is  extremely  simple;  and  when  there  is  no  disproportion 
between  the  head  and  the  pelvis,  and  some  slight  traction  is  alone 
required  to  supplement  deficient  expulsive  power,  the  operation  in 
the  hands  of  any  ordinary  well-instructed  jiractitioner  ought  to  be  per- 
fectly safe  both  to  the  mother  and  child.  It  is  very  different  when  the 
head  is  arrested  at  the  brim  or  high  in  the  pelvis.  Then  the  application 
of  the  forcei^s  is  an  operation  re(piiring  much  (U'xterity  for  its  ])r(>per 
performance,  and  must  never  be  undertaken  without  anxious  considera- 
tion. It  is  because  these  two  classes  of  operations  have  been  confused 
that  the  use  of  the  instrument  is  regarded  by  many  Avith  such  unreason- 
able dread. 


Tin-:  F(  J  IK 'EPS.  485 

Preliminary  Considerations. — Before  attemptinjir  to  introduce  the 
forceps  there  are  several  points  to  which  attention  .should  be  directed: 

1st.  friie  nienibranes  must  of  course  be  ruptured.) 

2dly.  (For  the  safe  and  easy  application  of  the  instrument  it  is  also 
advisable  that  the  os  sliouhl  be  iuHy  dilated  and  the  cervix  retracted 
over  the  heatt)  Still,  tliesc  two  points  cannot  be  regarded,  as  many 
have  laid  down,  as  being  sine  qud  non.  Indeed,  we  are  often  compelled 
to  use  the  instrument  when,  although  the  os  is  fully  dilated,  the  rim  of 
the  cervix  can  be  felt  at  some  point  of  the  contour  of  the  head,  espe- 
cially in  cases  iu  which  the  anterior  lip  is  jammed  between  the  head 
and  the  pubes.  Provided  due  care  be  taken  to  guard  the  cervical  rim 
with  the  fingers  of  one  hand  as  the  instrument  is  slipped  past  it,  there 
need  be  no  fear  of  injury  from  this  cause.  If  the  os  be  not  fully 
dilated,  but  is  sufficiently  open  to  admit  of  the  passage  of  the  forceps, 
the  operation,  under  urgent  circumstances,  may  be  quite  justifiable,  but 
it  must  necessarily  be  a  somewhat  anxious  one. 

3dly.(The  position  of  the  head  should  be  accurately  ascertained  by 
means  of  the  sutures  and  fontanelles.^  Unless  this  be  done  the  opera- 
tion will  always  be  haphazard  and  unsatisfactory,  as  the  practitioner  can 
never  be  in  possession  of  accurate  knowledge  of  the  progress  of  the 
case.  It  may  be  that  the  occiput  is  directed  backward;  and,  although 
that  does  not  contraindicate  the  application  of  the  forceps,  it  involves 
special  precautions  being  taken. 

4thly.  i.The  bladder  and  bowels  should  be  emptied.) 

Question  of  Administering-  Anaesthetics. — Before  proceeding  to 
operate  the  question  of  anaesthesia  will  arise.  In  any  case  likely  to 
be  difficult  it  is  of  the  greatest  assistance  to  have  the  patient  com- 
pletely under  the  influence  of  an  anaesthetic  to  the  surgical  degree,  so 
as  to  have  her  as  still  as  possible ;  but  whenever  this  is  deemed  neces- 
sary another  practitioner  should  undertake  the  responsibility  of  the 
administration.  In  simple  cases  I  believe  it  is  better  to  dispense  with 
anaesthetics  altogether,  partly  because  they  are  apt  to  stop  what  pains 
there  are — which  is  in  itself  a  disadvantage — but  chiefly  because  under 
partial  anaesthesia  the  jiatient  loses  her  self-control,  is  restless,  and  twists 
herself  into  awkward  positions  which  give  rise  to  the  utmost  difficulty 
and  inconvenience  in  the  use  of  the  instrument.  Moreover,  if  no  anaes- 
thetic be  given  the  patient  can  assist  the  operator  by  placing  herself  iu 
the  most  convenient  attitude. 

Description  of  the  Operation. — In  describing  the  method  of  applv- 
ing  the  f  )rceps  I  shall  assume  that  we  have  to  do  with  the  simpler 
variety  of  the  operation,  when  the  head  is  low  in  the  pelvis.  Subse- 
quently I  shall  point  out  the  peculiarities  of  the  high  operation. 

As  to  the  position  of  the  patient,  I  believe  there  can  be  no  doubt  of 
the  superiority  of  that  which  is  usually  adopted  in  Great  Britain.  /On 
the  Continent  and  in  America  the  forceps  is  always  employed  with  The 
patient  lying  on  her  back — a  position  involving  much  needless  exposure 
of  the  person  and  requiring  more  assistance  from  others. )  In  certain 
cases  of  unusual  difficulty  the  position  on  the  back  is  of  unquestionable 
utility,  but  we  may  at  least  commence  the  operation  in  the  usual  way, 
and  subsequently  turn  the  patient  on  her  back  if  desirable. 


486 


OBSTETRIC  OPERA  TIOXS. 


Much  of  the  i'acility  Avith  mIucIi  the  hhiclos  are  intrfxhicod  depends 
on  the  patient's  being  properly  j)hieed.  (Plence,  ahhough  it  gives  rise 
to  a  h'ttle  more  trouble  at  lirst,  I  believe  that  it  is  always  best  to  pay 
particular  attention  to  this  point,  whether  the  hitrh  or  low  forceps  ope- 
ration l)e  about  to  be  performed.  vThe  patient  should  be  brought  quite 
to  tlie  side  llf_,thej.)ed,  with  her  nates  jja rail el_ to  and  projecting  some- 
Avhat  over  its  edge.  The  body  should  lie  almost  directly  across  the  lu'd, 
and  nearly  at  right  angles  to  the  hips,  with  the  knees  raised  toward  the 
iabdomen  (Fig.  167).     In  this  way  there  is  no  risk  of  the  handle  of  the 


Fig.  167. 


Position  of  Patient  for  Forceps  Delivery,  and  Mode  of  Introducing  Lower  Blade 


upper  blade,  Avhen  depressed  in  introduction,  coming  in  contact  with  the 
bed. 

The  blades  should  be  warmed  in  tepid  water,  lubricated  with  cold 
cream  or  carbolized  vaseline,  and  placed  ready  to  hand. 

These  ])reliminaries  having  been  attended  to,  we  ])roceed  to  the  intro- 
duction of  the  blades,  sitting  by  the  side  of  the  bed  opposite  the  nates 
of  the  patient. 

The  imjiortant  question  now  arises,  In  what  direction  are  the  blades 
to  be  ])nssed  ?  The  almost  universal  rule  in  our  standard  works  is  that 
they  must  be  passed  as  nearly  as  ])ossible  over  the  child's  cars,  without 
any  reference  to  the  pelvic  diameters.  Hence,  if  tlie  licad  have  not  made 
its  turn,  but  is  lying  in  one  oblique  diameter,  the  blades  would  require 
to  be  passed  in  the  opposite  oblique  diameter;  in  .short,  the  posi- 
tion of  the  forcejis  as  regards  the  jielvis  must  vary  according  to  the 
position  of  the  head.  Some  have  even  laid  down  the  rule  that  the  for- 
ceps is  contraindicatcd  unless  an  ear  can  be  felt — a  rule  that  would  very 
seriously  limit  its  aj^plication,  as  in  many  ca.ses  in  which  it  is  urgently 
required  it  is  a  matter  of  great  difficulty,  and  even  impossibility,  to  feel 
the  ear  at  all.  Tit  is  admitted  that  in  the  high-forceps  operation  the 


THE  FORCEPS.  487 

blades  must  be  introduced  in  the  transverse  di_an7.eter  of  the  pelvis, 
without  relation  to  the  position  of  the  lieiul)  On  the  Continent  it  is 
generally  reconnnended  that  this  rule  shouhl  be  a[)plied  to  all  cases  of 
forceps  delivery  alike,  whether  the  head  be  high  or  low;  and(,I  have 
now  for  many  yeai's  ado[)ted  this  plan  and  passed  the  blades  in  all 
cases,  whatever  be  the  position  of  the  head,  iii  the  transverse  diameter 
of  the  pfilvis,  Avithout  any  attempt  to  pass  them  over  tlic"  t)TpiirietaI 
ditniieteroi  the  child's  head.  )  Dr.  Barnes  points  out  with  great  force 
that,  do  what  we  will  and  attem])t  as  we  may  to  pass  the  blades  in  rela- 
tion to  the  child's  head,  they  find  their  way  to  the  sides  of  the  j^elvis, 
and  that  the  marks  of  the  fenestrfe  on  the  head  always  show  that  it  has 
been  gras])cd  by  the  brow  and  side  of  the  occiput.  Of  the  perfect  cor- 
rectness of  this  obser\'ation  I  have  no  doubt ;  hence  it  is  a  needless  ele- 
ment of  complexity  to  endeavor  to  vary  the  position  of  the  blades  in 
each  case,  and  one  which  only  confuses  the  inexperienced  practitioner 
and  renders  more  difficult  an  operation  which  should  be  simplified  as 
much  as  possible.  While,  therefore,  it  is  of  importance  that  the  precise 
position  of  the  head  should  be  ascertained  in  order  that  we  may  have 
ian  intelligent  notion  of  its  progress,  I  do  not  think  that  it  is  essential  as 
a  guide  to  the  introduction  of  the  forceps. 

Method  of  Introducing-  the  Lower  Blade. — As  a  rule,  the  lower 
blade,  lightly  grasped  between  the  tips  of  the  index  and  middle  fingers 
and  thumb,  should  be  introduced  first.  Poised  in  this  way,  we  have 
perfect  command  over  it  and  can  appreciate  in  a  moment  any  obstacle 
to  its  passage.  Two  or  more  fingers  of  the  left  hand  are  introduced 
into  the  vagina  and  by  the  side  of  the  head  as  a  guide.  The  greatest 
care  must  be  taken,  if  the  cervix  be  within  reach,  that  they  are  passed 
within  it,  so  as  to  avoid  the  possibility  of  injury. 

The  handle  of  the  instrument  has  to  be  elevated,  and  its  point  slid 
gently  along  the  palmar  surface  of  the  guiding  fingers  until  it  touches 
the  head  (Fig.  167).  At  first  the  blade  should  be  inserted  in  the  axis 
of  the  outlet,  but  as  it  progresses  the  handle  must  be  depressed  and 
carried  backward.  As  it  is  pushed  onward  it  is  made  to  progress  by  a 
slight  sideHto-side  motion,  and  it  is  of  the  utmost  importance  to  bear  in. 
mind  that  the  greatest  gentleness  must  always  be  used.  If  any  obstruc- 
tion be  felt  we  are  bound  to  withdraw  the  instrument  partially  or  entirely, 
and  attempt  to  manoeuvre,  not  force,  the  point  past  it.  As  the  blade  is. 
guided  on  in  this  way,  it  is  made  to  pass  over  the  convexity  of  the  head, 
the  point  being  always  kept  slightly  in  contact  Avith  it,  until  it  finally 
gains  its  proper  position.  When  fully  inserted  the  handle  is  drawn 
back  toward  the  perineum,  and  given  in  charge  to  an  assistant.  The 
insertion  must  be  carried  on  only  in  the  intervals  between  the  pains, 
and  desisted  from  during  their  occnnviicc,  otherwise  there  would  be 
a  serious  risk  of  injuring  the  soft  ])arts  t)f  the  mother. 

IntrodiTction  of  the  Upper  Blade. — The  second  blade  is  passed 
directly  opposite  to  the  first,  and  is  generally  somewhat  more  difficult 
to  introduce,  in  consequence  of  the  sjiace  occupied  by  the  latter.  It 
is  passed  along  two  fingers  directly  opjiosite  the  first  blade,  and  M'ith  ex- 
actly the  same  precautions'  as  to  direction  and  introduction,  except  that 
at  first  its  handle  has  to  be  depressed  instead  of  elevated  (Fig,  168j. 


488 


OBSTETRIC  OPERATIONS. 


The  handle  M'hich  was  in  charge  of  the  assistant  is  now  laid  hold  of 
by  the  operator,  and  the  two  handles  are  drawn  together.    If  the  blades 


Fig.  168. 


Introduction  of  the  Upper  Blade. 


have  been  properly  introduced,  there  should  be  no  difficulty  in  locking; 
but  should  we  be  unable  to  join  them  easily,  we  must  withdraw  one  or 


Fig.  169. 


Forceps  in  Position  :  Traction  in  the  Axis  of  the  Brim  Downward  and  Backward. 

other,  either  partially  or  entirely,  and  reintroduce  it  with  the  .<aine  pre- 


THE  FORCEPS. 


489 


cautions  as  before.    We  must  also  assure  ourselves  that  no  hairs  nor  any 
of  the  maternal  structures  are  caught  in  the  lock. 

Method  of  Traction. — When  once  the  blades  are  locked  we  may 
commence  our  eiforts  at  traction.  To  do  this  we  lay  hold  of  the 
handles  with  the  right  hand,  using  ^uly  sufficient  compression  to  give 
a  firm  grasp  of  the  head  and  to  keep  the  blades  from  slipping.)  The 
left  hand  may  be  advantageously  used  in  assisting  and  supporting  the 
right  during  our  efforts  at  extraction,  and  at  a  late  stage  of  the  opera- 
tion may  be  employed  in  relaxing  the  perineum  when  stretched  by  the 
head  of  the  child.  (Traction  must  always  be  made  in  reference  to  the 
pelvic  axesy  being  at  first  backward  toward  the  perineum  (Fig.  169),  in 
the  direction  of  the  axis  of  the  brim ;  and  as  the  head  descends  and  the 
vertex  protrudes  through  the  vulva,  it  must  be  changed  to  that  of  the 
outlet  (Fig.  170).     If  the  axis-traction  forceps  is  used,  it  is  to  be  borne 

Fig.  170. 


Last  Stage  of  Extraction  :  The  Handles  of  the  Forceps  are  being  gradually  turned  upward 
toward  the  Mother's  Abdomen. 


in  mind  that  traction  is  to  be  made  by  the  traction  handle  only,  the 
handles  of  the  instrument  itself  being  left  untouched  after  they  are 
locked  and  the  traction-rods  are  united.  By  keeping  these  latter 
parallel  to  the  handles  of  the  forceps,  traction  can  always  be  made  in 
the  proper  direction.  (  We  must  extract  only  during  the  pams,  and  if 
these  should  be  absent  we  must  imitate  them  by  acting  at  intervals.) 
This  is  a  point  Avhich  deserves  special  attention,  for  there  is  no  more 
common  error  than  undue   hurry  in  delivery. 

The  only  valid  objection  I  know  of  against  a  more  frequent  resort  to 


490  OBSTETRIC  OPERATIONS. 

the  forceps  in  linj;crin;^-  labor  is  lliat  (lie  sudden  ciiiptyiiig;  of  the  uterus 
in  the  absence  of"  pains  may  pralispose  to  heni<.)rrh:io;c ;  and  it  cannot 
be  denied  that  it  is  one  of  some  weiglit.  However,  if  due  care  be 
taken  to  operate  slowly  and  to  allow  several  minutes  to  elapse  between 
I'aeh  tractive  ctt'ort,  while  at  the  same  time  uterine  contractions  be 
stimulated  bv  pressure  and  support,  tliis  ne(Kl  not  be  considered  a 
contraindication.  ]>esidcs  direct  traction  we  may  impart  to  the  instru- 
ment a  uentle  waviny;  motion  from  handle  to  handle,  which  briny;s  into 
ojieration  its  power  as  a  lever ;/  but  this  must  be  done  only  to  a  very 
slii^ht  extent  and  must  always  be  subservient  to  direct  traction. j 

Proceedinti;  thus  in  a  slow  and  cautious  manner,  carefully  re<rulating 
the  force  emj)l<)ved  according  to  the  exigencies  of  the  case,  we  shall  per- 
ceive that  the  head  begins  to  descend  ;  and  its  ])rogress  should  be  deter- 
mined from  time  to  time  by  the  fingers  of  the  unemployed  hand. 

(When  the  head  lies  in  the  oblique  diameter,  as  it  descends  in  couse- 
c^uence  of  its  perfect  adaptation  to  the  pelvic  cavity,  it  will  turn  into  the 
antero-])osterior  diameter  without  any  effort  on  the  part  of  the  operator, 
provided  only  that  the  traction  be  sufficiently  slow  and  gradual.)  As 
the  head  is  about  to  emerge  it  is  necessary  to  raise  the  handles  toward 
the  mother's  abdomen.  More  than  usual  care  is  required  to  prevent 
laceration  of  the  perineum,  which  is  always  much  stretched  (Fig.  170). 
I  If,  as  often  happens,  the  pains  have  now  increased  and  the  perineum  be 
very  thin  and  tense,  it  may  even  be  desirable  to  remove  the  blades 
gently  and  leave  the  case  to  be  terminated  by  the  natural  })0wers^  but 
if  due  precautions  are  used  this  need  not  be  necessary. 

The  peculiarities  of  forceps  delivery  in  occipito-posterior  positions 
have  already  been  discussed  (p.  326),  and  need  not  be  repeated. 

High  Forceps  Operations. — When  the  high  forceps  operation  has 
been  decided  on  the  passage  of  the  blades  will  be  found  to  be  much 
more  difficult,  from  the  height  of  the  presenting  part,  the  distance 
which  they  must  pass,  and  m  some  cases  from  the  mobility  of  the  head 
interfering  Avith  their  accurate  adaptation.  The  general  ])rinciples  of 
introduction  and  of  traction  are,  however,  identical.  If  the  operation 
be  attempted  before  the  head  has  entered  the  ]x4vic  brim, (it  must  be 
fixed  as  much  as  possible  by  abdominal  pressure. '  In  guiding  the 
blades  to  the  head  special  care  must  be  taken  to  avoid  anv  injury  of 
the  soft  parts,  especially  if  the  cervix  be  not  completely  out  of  reach. 
For  this  purpose  it  may  even  be  advisable  to  introduce  the  entire  left 
hand  as  a  guide,  so  as  to  avoid  any  possibility  of  injuring  the  cervix 
from  not  passing  the  instrument   under  its  edge. 

Peculiar  Method  of  Introducing-  the  Blades.— Some  antlioi-s 
advise  that  in  such  cases  the  blade  should  be  introduced  at  first  oppo- 
site the  sacrum  until  the  point  apjiroaches  its  promontory.  Ft  is  then 
made  to  sweep  round  the  pelvis  under  the  protecting  fingers  till  it 
reaches  its  proper  position  on  the  head.  )  This  plan  is  advocated  by 
Ramsbotham,  Hall  Davis,  and  other  eminent  practical  accoucheurs ; 
and  it  is  certainly  of  service  in  some  cases  of  ditlieulty,  especially 
when,  from  any  reason,  it  is  not  possible  to  draw  the  nates  over  the 
edge  of  the  bed,  when  the  necessary  depression  of  the  handle  of  the 
upper  blade  is  difficult  to  effect.     It  involves,  however,  a  somewhat 


THE  FORCEPS.  491 

eomplicatcfl  iiianrpuvu'c,  and  it  is  seldom  that  the  blades  cannot  be 
readily  introduced  in  the  usual  way. 

In  locking  the  slightest  approach  to  roughness  must  be  carefidly 
avoided,  for  the  extremities  of  tiie  blades  are  now  within  the  cavity  of 
the  uterus  and  serious  injury  might  easily  be  inflicted.  If  difficulty  be 
met  witii,  rather  than  emphn'  any  force  one  of  the  blades  should  be  with- 
drawn and  reintroduced  in  a  more  favorable  direction.  If  the  blades 
have  shanks  of  sufficient  length,  there  should  be  no  risk  of  including 
the  soft  parts  of  the  mother  in  the  lock,  which  in  a  badly-constructed 
instrunient  is  an  accident  not  unlikely  to  occur. 

Method  of  Traction.— ^After  junction,  traction  must  at  first  be  alto- 
gether in  the  axis  of  the  brim,  and  to  effect  this  the  handles  must  be 
pressed  M'ell  backward  to\vard  the  perineum.;  As  the  head  descends  it 
Avill  probably  take  the  usual  turn  of  itself,  without  effi3rt  on  the  part 
of  the  operator,  and  the  direction  of  the  tractive  force  may  be  gradually 
altered  to  that  of  the  axis  of  the  outlet.  ■  If  the  pains  be  strong  and 
regular,  aud  there  be  no  indications  for  immediate  delivery,  we  may 
remove  the  forceps  after  the  head  has  descended  upon  the  perineum,  and 
leave  the  conclusion  of  the  case  to  nature.  ■  This  course  may  be  especi- 
ally advisable  if  the  perineum  and  soft  parts  be  unusually  rigid,  but 
generally  it  is  better  to  terminate  labor  without  removing  the  instru- 
ment. 

Possible  Danger  of  Forceps  Delivery. — Before  concluding  this 
subject  reference  may  be  made  to  the  possible  dangers  of  the  operation. 
I  would  here  again  insist  on  the  importance  of  distinguishing  between 
the  high  and  low  forceps  operations,  which  have  been  so  unfortunately 
and  unfairly  confounded.  Reasons  have  already  been  given  for  reject- 
ing the  statistics  of  the  risks  attending  forceps  delivery  in  the  latter 
class  of  cases  (p.  353).  A  formidable  catalogue  of  dangers,  both  to 
mother  and  child,  might  easily  be  gathered  from  our  standard  works 
on  obstetrics.  Among  the  former  the  principal  are'  lace!ratious  of  the 
uterus,  vagina,  and  perineum  jM'upture  of  varicose  veins,  givuig  rise  to 
thrombus;  pelvic  abscess  from  contusion  oT  the  soft  parts -(subsequent 
inflammation  oftlie  uterus  or  peritoneun^;(^'tearing  asunder  of  the  joints 
and  symphyses);  and  even  'fracture  of  the  pelvic  bones.  A  careful 
analysis  of  these,  such  as  has  been  so  well  made  by  Drs.  Hicks  and 
Phillips,^  proves  beyond  doubt  that  the  application  of  the  instrument  is 
not  so  nuich  concerned  in  their  production  as  the  protraction  of  the 
labor  and  the  neglect  of  the  practitioner  in  not  interfering  sufficiently 
soon  to  prevent  the  occurrence  of  the  evil  consequences  afterward  attrib- 
uted to  the  operation  itself.  Many  of  these  will  be  found  to  rise  from 
the  prolonged  jiressure  on  the  soft  parts  within  the  pelvis  and  the  sub- 
sequent inflammation  or  sloughing.  To  these  causes  may  be  referred 
with  propriety  most  cases  of  vesico-vaginal  fistula  (p.  446),  peritonitis, 
and  metritis  following  instrumental  labor. 

Lacerations  and  similar  accidents  may,  however,  result  from  an  incau- 
tious use  of  the  instrument.  Slight  lacerations  of  the  mucous  mem- 
brane of  the  vagina  are  probably  far  from  uncommon.  But  if  these 
cases  were  closely  examined  it  would  be  found  that  the  fault  lay  not  in 

'  Obst.  Trans.,  1872,  vol.  xiii.  p.  55. 


41)2  onsTKTiuc  orERATJoys. 

the  iiistriiniC'iit,  Imt  in  the  hand  that  used  it.  Either  the  hlades  w<Te 
iiitnuliieed  without  (hie  ret:;ard  to  the  axes  of  the  j)elvis,  or  tliey  were 
jMislied  forward  with  loree  and  vicjleuce,  or  an  instiuinient  wils  enij)lovcd 
unsuital)le  to  the  ease  (sueh  as  a  short  straight  foreeps  when  the  liead 
was  high  in  the  jK'lvis),  or  undue  liaste  and  force  in  deliver^'  were  used. 
It  would  be  manifestly  unfair  to  lay  the  blame  of  sueh  results  upon  the 
forceps,  which  in  the  hands  of  a  more  judicious  and  experienced  prac- 
titionei-  would  have  effected  the  desired  object  with  perfect  safety.  The 
instrument  is  doubtless  unsafe  in  the  hands  of  any  one  wlio  does  not 
understand  its  use,  just  as  the  scalpel  or  amputating-knife  would  be  in 
the  hands  of  a  rash  and  inexperienced  surgeon.  The  le&son  to  be  learnt 
seems  to  be  clearly,  not  that  the  dangers  should  deter  us  from  the  use 
of  the  forceps,  but  that  they  should  induce  us  to  study  more  carefully 
the  cases  in  which  it  is  aj)})licable  and  the  method  of  using  it  with 
safety. 

Possible  Risks  to  the  Child. — The  dangers  to  the  child  are,  prin- 
cipally, lacerations  of  the  integuments  of  the  scalp  and  forehead  ;  con- 
tusion of  the  face;  partial  but  temporary  paralysis  of  the  face  from 
pressure  of  a  blade  on  the  facial  nerve ;  depression  or  fracture  of  the 
cranial  bones;  injury  to  the  brain  from  undue  pressure  of  the  blades. 
These  evils  are  of  I'are  occurrence,  and  when  they  do  happen  generally 
result  from  improper  management  of  the  operation — such  as  undue  com- 
pression, the  use  of  improper  instruments,  or  excessive  and  ill-directed 
efforts  at  traction — and  cannot  therefore  be  considered  as  in  any  way 
contraindicating  the  use  of  the  instrument.  ^Nlany  of  the  more  common 
results,  such  as  slight  abrasions  of  the  scalp  or  paralysis  of  the  face,  are 
transitory  in  tlioir  nature  and  of  no  real  consequence. 

[The  Forceps  in  America. — Although  the  obstetrical  forceps  was 
first  used  in  Englaud,  other  countries  in  the  march  of  im])rovement 
have  made  great  changes,  not  only  in  the  original  forms,  but  in  the  man- 
ner of  use,  and  various  shapes,  as  well  as  different  positions  of  the 
woman  in  application,  have  become  in  a  measure  national.  AVith  the 
exception  of  having  adopted  almost  exclusively  the  French  and  German 
dorsal  decubitus  in  makino;  use  of  the  instrument,  we  have  become  in  a 
measure  eclectic  in  the  selection  of  the  latter ;  medical  schools,  accouch- 
eurs, and  local  obstetrical  societies  influencing  students  and  the  junior 
members  of  the  profession  to  adopt  the  French,  German,  English,  or 
American  style,  as  the  case  may  be,  the  forcej)S  themselves  bearing  the 
names  of  the  several  inventors  or  compilers  ;  ft)r  some  are  a  true  com- 
j)ilation — the  blade  from  one  contriver;  fenestral  openings,  another; 
pelvic  curve,  a  third  ;  width,  a  fourth  ;  shanks,  a  fifth  ;  method  of  lock- 
ing, a  sixth  ;  etc.  etc.  For  this  reason  the  late  Prof  Hodge  named  his 
forceps  the  eclectic,  although  in  some  respects  entirely  oi-iginal,  ])articu- 
larly  in  the  long  superimposed  shanks — a  great  improvement  for  ojw- 
rating  at  the  superior  strait  and  av(»i(ling  the  painful  stretching  of  the 
posterior  ef)mmissure  of  the  vulva.  Pr.  Hodge  expended  a  great  deal 
of  thought  and  money  in  perfecting  his  forceps,  and  the  various  steps 
in  the  process  were  marked  by  a  new  form,  until,  from  a  heavy,  clumsy 
instrument,  he  gradually  evolved  what  was  at  one  time  regarded  as  a 
wonderful  improvement  upon  the  forceps  of  France  and  England. 


THE  FORCEPS.  493 

(^  A  contemporary  of  Prof.  Hodge,  the  late  Prof.  David  D.  Davis  of 
London,  was  o(jiially  anxious  to  perfect  the  instrument,  and  turiied  liis 
attention  especially  to  makinij:  the  blades  li_i;ht,  ope^i,  and  to  fit  the  sides 
of  the  fcietal  head  so  as  to  enable  traction  to  be  made  without  much  pres- 
sure or  leaving  any  mark  on  the  child's  scalpj  There  is  a  principle  of 
mechanics  involved  in  his  instrument  which  he  studied  to  perfect  by 
moulding  the  blades  so  as  to  obtain  considerable  coaptating  surface,  and 
thus  by  increase  of  friction  to  avoid  undue  and  dangerous  pressure. 
The  Davis  blade  soon  began  to  effect  changes  in  the  form  of  American 
forceps,  and  by  the  addition  of  long  handles  and  some  alterations  of 
shape,  weight,  and  curve  became  a  leading  feature  in  those  bearing  the 
names  of  William  Harris,  Prof.  Wallace  of  the  Jefferson  Medical  Col- 
lege, Dr.  Bethel,  and  xVlbert  H.  Smith,  all  of  this  city.  The  short  Davis 
instrument  was  a  great  favorite  with  the  late  Prof.  Meigs  and  Dr.  Wil- 
liam Harris,  both  largely  engaged  in  obstetrical  practice  as  ^vell  as 
teaching ;  and  many  a  delicate  woman  with  wasting  forces  was  aided  in 
her  delivery  at  their  hands,  and  was  surprised  to  find  no  mark  on  the 
baby's  head,  and  that  her  own  suiferiugs  could  be  so  gently  and  safely 
relieved. 

Although  such  was  the  estimation  of  the  Davis  blade,  and  still  is  in 
many  parts  of  our  country,  it  does  not  appear  to  have  retained  its  popu- 
larity or  been  adopted,  as  its  mechanical  perfection  would  lead  one  who 
appreciates  it  to  suppose  it  would  have  been.  In  Great  Britain  the 
favorite  forms  now  in  use  are  but  a  very  slight  improvement  upon  the 
forceps  of  a  hundred  years  ago  except  in  finish  and  material,  the  open 
fenestrse  and  bevelled  blades  of  Davis  being  declined  in  favor  of  the 
looped  fenestree  and  flat-edged  blades  in  use  when  he  made  his  experi- 
ments and  changes.  This  appears  to  have  grown  out  of  a  practice  which 
has  been  largely  adopted  in  Germany,  Great  Britain,  and  many  parts  of 
the  United  States  in  applying  the  forceps  to  the  foetal  head,  the  blades 
being  introduced  at  the  sides  of  the  pelvis,  without  much  reference  to  the 
position  which  the  head  occupies.  As  compression  is  objected  to,  the 
blades  are  made  long  and  widely  separated  (3J  to  3|  inches),  ancl  the 
handles  short,  so  as  not  to  allow  of  much  leverage.  As  the  blades  do  not 
fit  the  head,  the  mechanism  of  labor  as  taught  by  Hodge  has  been  much 
simplified,  as  it  is  not  necessary  to  learn  all  the  oblique  fittings  of  the 
fenestrse  over  the  parietal  protuberances  or  ears.  Dr.  Meigs  used  to  tell 
the  students  that  the  forceps  was  the  "chikVs  insirument"  and  should 
be  used  as  a  tractor ;  and  it  was  as  a  well-applied  mechanical  tractor 
that  he  advocated  the  use  of  the  Davis  blades  against  those  of  Siebold, 
Levret,  Baudelocque,  and  Haightou,  employed  generally  in  our  country 
forty  years  ago.  His  language  is  not  very  complimentary  to  what  he 
denominates  by  distinction  " the  moiher^s  instrument"  the  form  being 
better  adapted  for  saving  the  woman  than  the  foetus.^ 

At  the  present  day  we  ]ia\'e  two  general  orders  of  forceps  in  use  in 
the  United  States,  under  each  of  which  may  be  placed  a  vast  number 
of  special  varieties  which  are  simply  changes  upon  one  or  the  other  gen- 
eral type  according  to  the  fancy  of  the  inventor.  At  the  head  of  one 
type  may  be  placed  the  long  forceps  of  Prof.  Hodge,  designed  to  be 

[  1  Obstetrics,  p.  540.] 


494  OBSTETRIC  OPERATIONS. 

adapted  to  the  sides  urtlic  child's  licad  in  all  ]»(»ssil)l('  eases;  and  ol'  tiie 
other,  those  of  Prof.  Sinij)sun  of  Edini)ur<!,h  or  their  n)odiHcation  by 
Profs.  Elliot  and  JJedford  of  New  York,  intentled  to  he  used  as  trac- 
tors, and  applied  in  reference  to  the  sides  of  the  mother's  pelvis,  rather 
than  to  those  of  the  infant's  liead. 

Takin<^  the  lonti;  ioreeps  of  Levret  and  JJaiidelocque  a.s  imjn'oved  and 
modified  hy  Hodge,  with  the  blades  of  Prof.  Davis  as  a  substitute,  and 
handles  of  less  curve  than  those  of  Hodge,  and  we  have  the  long  for- 
ceps of  Prof.  Ellerslie  AVallace,  late  of  Jefferson  Medical  College,  the 
most  free  I  uent  choice  of  those  who  purchase  forceps  of  the  manufacturers 
in  Philadeli)liia.  Next  in  order  are  the  instruments  of  Hodge,  Davis, 
and  Simpson,  Elliot,  Bedford,  and  a  few  others — in  all  about  a  dozen 
forms  that  vary  in  popularity.  The  improvement  of  the  late  Prof. 
Elliot  upon  the  instrument  of  Simpson  consists  in  narrowing  and  length- 
ening the  shanks,  widening  somewhat  the  fenestra?, elongating  the  blades, 
giving  greater  security  against  slipping  in  the  handles,  and  gauging  the 
distance  between  the  blades  by  a  milled-head  screw-stoj)  in  the  end  of 
the  handles:  the  shanks  and  l)lades  are  an  exact  coiniterpart  of  the 
Miller  forceps  of  England,  which  appeared  about  the  same  time  (1858). 

The  Hodge  forceps  Mas  based  in  its  contrivance  upon  the  following 
points  :  1.  The  instrument  should  be  shaped  to  the  contour  of  the  foetal 
head,  and  have  sufficient  play  to  allow  of  compression  where  the  pelvisf 
is  too  narrow  for  the  head   to  pass  in  its  normal  condition.     2.  Thci 
blades  should  be  so  arranged  in  reference  to  the  shanks  and  handles  as' 
to  enable  them  to  seize  the  head  of  the  foetus  in  its  biparietal  diameter 
at  the  superior  strait,  and  be  drawn  upon  in  the  direction  of  the  curve 
of  the  pelvic  canal  until  the  delivery  is  complete.     3.  The  long  forceps 
ought  to  be  competent  to  act  either  at  the  superior  strait  of  the  pelvis,! 
in  its  cavity,  or  at  its  outlet,  so  as  to  avoid  a  multiplicity  of  instruments 
and  their  attendant  expense.     And,  4.  The  instrument  should  not  cut 
the  scalp  of  the  child  if  properly  adjusted,  or  injure  the  soft  parts  of 
the  mother. 

It  would  be  folly  to  claim  that  all  this  could  or  has  been  accom- 
])lished,  as  there  must  necessarily  be  exceptional  cases  in  all  the  ])oints 
given;  hence  the  contrivance  of  the  forceps  of  Tarnier  and  C'leemanu 
for  certain  presentations  above  the  superior  strait,  and  the  long  and  short 
convertible  instruments  of  a  few  inventors.  There  are  many  cases  of 
labor  in  the  higher  walks  of  life  where,  although  there  is  no  obstruc- 
tion, still  the  women  require  manual  or  instrumental  assistance,  as  they 
cannot  deliver  themselves  for  want  of  sufficient  contractile  muscular 
force.  Such  women  require  that  the  forceps  used  should  be  easily 
introduced — should  act  simply  as  tractors,  control  the  movement  of  the 
foetal  head  by  being  well  fitted  to  its  shape,  and  leave  no  effect  upon 
the  scalp  or  vulva.  Although  these  recpiisites  may  be  filled  by  the 
Hodge  instrument,  it  is  this  class  of  cases  that  has  demanded  a  lighter 
and  more  roomy  pair  of  forceps,  such  as  that  devised  l)v  Davis. 

As  the  teaching  of  the  Jefferson  Medical  College  under  Dr.  Meigs 
favored,  as  we  have  stated,  the  forcoj^s  of  Davis,  so  his  successor.  Prof. 
Wallace,  in  carrying  out  in  a  measure  the  same  views,  combined  the 
blades  of  the  Davis  pattern  with  the  long  handles  of  Hodge  in  con- 


THE  FORCEPS. 


495 


triving  Avliat  is  known  os  the  ^' Wallace  forceps/'  now  so  much  in  use 
by  the  large  number  of  graduates  of  this  school.  As  compared  with 
the  Hodge  instrument,  it  is  1  inch  shorter  (15  inches  against  16);  the 
blades  are  of  the  same  length  (G  inches) ;  the  fenestra'  are  more  open  ; 
the  shanks  are  only  half  the  length,  giving  much  greater  compressing 


Fig.  171. 


Fig.  172. 


Fig.  173. 


Hodge  Forceps. 


Wallace  Forceps. 


Davis  Forceps. 


power ;  and  the  handles  are  of  the  same  measurement  from  pivot  to 
hooks.  Both  have  the  Siebold  lock,  over  which  we  believe  the  broad- 
topped  button  and  notch  to  po.ssess  some  advantages ;  and  the  Wallace 
is  somewhat  heavier  than  the  Hodge,  which  should  weigh  17  ounces. 

The  short  Davis  instrument  made  for  Prof.  Meigs  under  direction  of 
the  inventor  weighed  10|  ounces  and  measured  12  inches  in  length; 
fenestrse,  5  inches  long,  2  inches  wide ;  blades  separated  2f  inches ; 
handles,  4^  inches  to  lock,  which  was  of  the  Smellie  or  English  pat- 
tern. A  recently-purchased  pair  in  possession  of  the  editor  is  1  Sc- 
inches long,  with  5-inch  handles,  a  button  lock,  2-inch  close-set  shanks, 
and  6i-inch  blades.  I  believe  the  changes  are  decided  improvements, 
especially  the  lock  and  elongated  handles.  It  has  answered  admirably 
in  adynamic  cases  requiring  only  a  few  pounds  of  tractile  assistance. 


49() 


OBSTETRIC  OPERA  TIOSS. 


Fig.  175. 


TIk'  Davis  blades  have  l)eeii  added  to  long  handle.^,  and  the  Mhole 
made  of  steel  and  marvellously  light,  at  the  special  request  of  a  few 
accouclu  urs,  who  wished  them  to  aid  in  some  cases  of  arrest  at  the 
perintum. 

The  late  Prof.  (Jeorge  T.  I'^lliot  of  New  York,  who  received  much 
of  his  practical  obstetrical  training  in  the  Dublin  L\ing-in  Hospital, 
imbibed  the  teachings  of  the  English  school,  and  became  imj>res.sed  with 
the  value  of  the  system  as  taught  by  Simpson,  upon  the  principle  of 
whose  forceps,  modelled  somewhat  after  that  of  the  late  Prof,  Gunning 
S.  Bedford  of  Xew  York,  he  in  1858  presented  to  the  medical  profes- 
sion the  instrument  that  bears  his  name.  The  forceps  of  Prof,  liedford 
has  a  traction-ring  on  each  side  where  the  Elliot  has  a  cornu,  has  a  but- 
ton joint,  instead  of  a  Smellie,  has  no  screw  top,  and  has  diverging 
instead  of  superimposed  shanks.  These  j)oints  have  generally  been  con- 
sidered as  improvements,  and  hence  the  Elliot  has  taken  precedence  in 
large  measure  over  the  Bedford  instrument  in  Xew  York,  the  two  being 
the  leading  forceps  in  demand.  The  instrument  of  AVhite  of  Buffalo  is 
perhaps  next,  and  then  Hodge's.  But  few  of  Prof.  "Wallace's  force])S, 
long  the  leading  instrument  in 
Fig.  174.  Philadelphia  sales,  are  ordered. 

The  Wliite  is  a  long  forceps,  a 
compound  of  the  Elliot  blade, 
long  superimposed  shanks  of 
Hodge,  Siebold  lock,  and  short 
corrugated  steel  handles  bowed 
out  like  dental  forceps  and  end- 
ing in  thin  blunt  hooks. 

The  Sawyer  and  Simpson 
short  forceps  are  said  to  be 
about  equally  in  demand  in 
Xew  York.  The  former  is 
almost  unknown  in  Philadel- 
phia, and  but  comparatively  few 
of  the  Simpson  are  asked  for,  al- 
though the  system  of  their  appli- 
cation has  several  advocates  in 
this  city. 

The  Sawyer  Forceps. — This 
is  the  lightest  of  all  the  varieties 
of  the  short  forceps,  weighing 
but  5  ounces,  and  measuring  Of 
inches  in  length;  the  handle 
being  3  inches,  shank   li,  and  sawyer  Forceps, 

chord  of   blade-curve  b\.     The 

blades  are  1 J  inches  wide,  with  oval  fenestra  |  inch 
wide,  and  separated  2§  inches  at  their  widest  j>art  and 
I  inch  at  the  tips.  This  in.strument  was  invented  eight 
yeai-s  ago  by  Prof.  Edw.  A\'arren  Sawyer  of  Rush  IMed- 
ical  College,  Chicago,  and  has  been  highly  commended  by  Prof,  By  ford 
and  others.     The  forceps  has  the  blades  of  Davis,  superimpo.sed  shanks 


Elliot  Forceps. 


THE   FORCEPS.  497 

of  Hodge,  and  lo(;k  of  Sniellio,  wiiii  liardrubbcr  plates  moulded  hot 
upon  the  handles.  The  several  parts  have  been  somewliat  modified,  the 
objeet  being  to  seen  re  a  traetor  for  cases  of  deficient  expulsive  force  where 
the  foetal  head  is  low  in  the  pelvis. 

Professor  Sawyer  says:  "In  the  labors  to  which  my  forceps  is  appli- 
cable it  is  not  necessary  for  the  operator's  body  to  be  in  line  with  the 
pelvic  axis.  My  mode  of  procedure  is  the  following:  The  woman  is 
placed  u])on  her  back  and  drawn  to  the  edge  of  the  bed  ;  the  outside  leg 
is  now  flexed  ;  beneath  this  flexed  extremity  and  the  bed-covering  I 
apply  the  forceps — often  using  but  one  hand  in  the  operation.  When 
the  instrument  is  locked,  I  grasp  the  handle  in  such  a  manner  that  the 
palm  of  the  hand  looks  upward ;  one  hook  then  rests  naturally  upon 
the  extensor  surface  of  the  first  phalanx  of  the  index  finger,  while  the 
other  hook  rests  upon  a  corresponding  part  of  the  thumb.  When  thus 
adjusted,  I  lift  the  head  from  the  pelvic  outlet,  at  the  same  time  invok- 
ing the  pendulum  movement  if  desired.  At  this  moment  the  advan- 
tage of  the  hooked  handle  is  very  apparent  to  the  operator."  .... 
"AH  practitioners  must  have  often  felt,  during  the  last  moments  of  labor, 
when  the  uterus  and  the  mother  seemed  fatigued,  the  need  of  a  little  help 
to  the  expulsive  powers.  The  ordinary  instruments  are  too  formidable 
to  be  used  at  the  last  moment,  and  it  is  then  that  this  little  forceps  is 
useful." 

I  have  given  the  names  and  characters  of  the  various  forceps  most  in 
use  in  New  York  and  Philadelphia,  and  by  the  large  number  of  gradu- 
ates of  their  respective  schools,  as  shown  by  their  preferences  in  select- 
ing instruments  of  the  leading  makers  of  the  two  cities.  [  The  mechan- 
ism of  instrumental  delivery  is  much  simplified  by  applying  the  forceps 
to  whatever  parts  of  the  foetal  head  may  be  opposite  the  sides  of  the 
pelvis,  but  it  is  very  questiouable  whether  it  is  the  scientific  method 
or  the  safer  for  the  child.\  With  one  blade  over  the  side  of  the  occiput, 
and  the  other  over  that  of  the  forehead — which  is  the  manner  of  seizure 
in  oblique  positions  of  the  vertex — we  certainly  have  not  a  very  secure 
hold  and  run  some  risk  of  injury  to  the  foetus.  The  advocates  of  this 
system  claim  that  they  use  no  compression,  only  a  simple  traction ; 
which  may  be  true  in  one  sense,  but  amounts  to  the  same  in  effect,  else 
how  could  Dr.  Elliot,  by  traction  with  great  force,  straighten  out  one 
of  the  blades  of  his  Simpson  forceps,  as  related  in  the  JSVw  YorJ:  Journ. 
of  Medicine  for  September,  1858,  p.  161,  in  the  paper  which  he  pre- 
sented describing  his  new  forceps  and  a  number  of  cases  in  which  he 
had  tested  them  ?  It  makes  but  little  difference  whether  we  compress 
the  head  before  we  begin  to  pull,  or  pull  so  as  to  wedge  the  head 
between  the  blades,  and  thus  compress  it,  except  as  to  the  difference  of 
fit  in  the  two  instances ;  the  adjusted  and  even  pressure  being  the  less 
likely  to  injure  the  foetus.  I  have  always  believed  that  the  forceps 
should  fit  the  head,  and  that  the  student  should  be  taught  how  to 
accomplish  it  correctly  in  the  various  positions  of  the  foetus.  If  the 
student  has  a  mechanical  turn  of  mind,  a  delicate  sense  of  touch,  and  a 
clear  head,  he  will  soon  learn  ;  if  he  is  not  a  mechanic,  he  will  be  forced 
to  adopt  a  more  simple  method  of  delivery.  In  a  large  city  there  are 
but  few  first-class  obstetrical  manipulators  as  a  general  rule,  and  they 

32 


498 


OBSTETRIC  OPEliA  TlnXS. 


liw  usually  well  kiK)\vn  as  such,  for  tlu-  rea.M»u  that  l)ut  lew  have  all  the 
reijuisiti'S  t(»  enable  tlieiu  to  achieve  not<jriety  ;  and  yet  there  are  hun- 
dreds who  can  deliver  a  woman  with  forceps  moderately  well.  T(»  one 
the  mechanism  of  llmlge  is  a  simple  matter  and  soon  mastered;  to 
anotlicr  it  is  a  useless  complication,  and  he,prefei-s  the  more  simple  sys- 
tem. Ilencc  the  irreat  differences  ijetween  obstetricians  as  to  tlie  best 
instruiueut  and  the  best  method  of  application.  Some  of  the  vast  arr.iy 
of  j)atterDS  have  decided  merit  and  display  much  mechaniial  skill,  while 

Flo.  17G. 


Application  of  the  Forceps  at  the  InRrior  Strait. 


Others  serve  only  to  amuse  the  edu("ated  examiner.  One  obstetrician, 
after  the  manner  of  Elliot,  u.ses  a  variety  of  forcei)s  one  after  another  in 
the  same  case,  and  \m\h  with  great  force,  while  another  confines  his 
work  almost  to  one  instrument,  adjusts  it  easily,  pulls  moderately,  and 
seldom  fails.  There  are  no  doubt  exceptions,  but  certaiidy  the  most 
delicate  manipulators  we  have  seen  believed  in  and  jiractised  the  teach- 
ings of  Hodge  and  ^leigs.  There  may  be  cases  where  it  might  be  well 
to  practise  the  method  of  Simpson,  as  is  done  occasionally  by  some  of 
our  leading  practitir>ners,  but  we  cannot  see  why  his  plan  of  delivery 
should  be  exclusivelv  used  on  anv  mode  of  scientific  reasoning. 


THE  FORCEPS. 


409 


I  present  a  series  of  plates  in  illustration  of  the  American  method  of 
delivery  with  the  force])s,  the  position,  as  will  be  seen,  being  that  of 
France  and  Germany — on  the  back.  AVhen  it  is  decided  to  use  the  for- 
ceps, in  almost  all  cases  in  the  United  States  the  patient  is  brought  to 
the  edge  of  the  bed  on  her  back,  with  her  nates  close  to  the  edge,  her 
feet  on  two  chairs,  and  her  knees  widely  se2)arated,  as  in  the  plate  above. 
The  patient  is  covered  with  a  sheet,  or  heavier  covering  if  in  winter, 
and  there  is  no  necessity  of  exposure,  as  the  whole  manipulation  may 
be  done  by  the  sense  of  touch.  The  position  is  by  far  the  most  con- 
venient for  the  obstetrician,  and  enables  him  much  more  easily  to  keep  in 


Fig.  177. 


Application  ol  the  Forceps  with  the  Head  at  the  Superior  Strait,  the  left  blade  held  in 
place  by  an  assistant. 

his  mind  all  the  anatomical  relations  of  the  foetus  and  pelvis  than  when 
in  the  English  decubitus.  We  study  the  anatomy  with  the  subject  on 
the  back,  and  the  mechanism  of  labor  in  front  of  the  pelvis  or  manikin  ; 


500 


OBSTETRIC  OPERATIONS. 


thou  why  eonij)lieatc'  iiiatters  bv  a  chaii<i;L'  of"  position,  which,  to  say  the 
least,  is  a  very  awkward  one,  })artieuhu'ly  in  introducing  the  long  for- 
ceps, setting  it  according  to  the  instructions  of  Hodge,  and  carrying  it 
forward  between  the  thighs  as  the  head  emerges?  I  have  used  the  siiort 
forct'ps  in  an  exhausted  case  with  the  woman  on  her  side,  but  found  it 
much  less  convenient  for  the  various  movements,  although  I  soon  deliv- 
ered the  foetus.  As  to  the  question  of  exposure,  there  is  less  in  appear- 
ance than,  in  fact,  in  the  English  position  in  many  cases.  If  the  patient 
and  nui-se  are  fastidious  and  careful  during  the  use  of  the  forceps,  the 
accoucheur  can  manage  without  his  eyes  in  a  large  proportion  of  cases ; 
but  the  fault  of  exposure  lies  more  frequently  in  the  temporary  reckless 
indiifereuce  begotten  of  pain  and  suffering  in  tlie  woman,  than  in  any 
act  of  the  accoucheur  if  inclined  to  spare  the  feelings  of  his  patient  as 
much  as  possible. 

The  long  forceps,  Mith  its  pelvic  curve,  was  specially  designed  for 
use  at  the  superior  strait  of  the  pelvis,  the  curve  of  the  blades,  as  in 
the  Davis  instrument  modified  by  "\^'allace,  being  intended  to  corre- 


Fio.  178. 


DireclJon  of  the  Forceps  as  the  Head  is  being  Delivered. 

spond  with  the  direction  of  the  occipito-mental  diameter  of  the  fa^al 
head.  The  long  sui)erimposed  shanks  of  several  varieties  of  the  long 
forceps  will  here  be  found  valuable,  as  the  lock  is  not  introduced  or 
the  posterior  commissure  of  the  vulva  widely  stretched.     If  the  head 


THE  FORCEPS.  501 

is  entirely  above  the  strait,  the  line  of  tlic  blades  must  be  changed 
correspondingly,  in  order  to  apply  them  properly  and  keep  the  line 
of  traction  within  tlu;  coccyx;  and  even  then,  to  draw  in  the  proper 
direction,  the  left  hand  must  act  at  tirst  in  a  backward  direction  fnjin 
the  lock,  while  the  right  brings  the  handles  downward,  forward,  and 
then  upward ;  both  hands  describing  a  curve,  but  that  of  the  right 
being  much  the  greater.  The  peculiar  forceps  of  Tarnier  or  of  Clee- 
mann,  being  designed  to  meet  this  form  of  exigency,  may  be  brought 
into  requisition.     These  both  have  the  blades  of  Davis. 

In  latter  years  it  has  become  much  more  common  than  formerly  to 
introduce  the  forceps  into  the  uterus  before  it  is  fully  dilated,  in  conse- 
quence of  the  success  claimed  for  the  plan  as  carried  out  in  the  Dublin 
Lying-in  Hospital.  As  this  should  never  be  done  where  the  os  is  not 
readily  dilatable,  aud  requires  much  skill  in  execution,  it  is  not  safe  to 
recommend  its  general  adoption  in  cases  of  delay  in  private  practice. 

The  forceps  should  not  be  introduced  with  any  force,  but  the  left 
blade  should  be  slid  in  gently  and  with  a  spiral  motion,  and  then  the 
right,  care  being  taken  tliat  they  should  also  lock  without  force,  which 
they  will  do  if  properly  adjusted.  Traction  is  to  be  exerted  slowly 
and  during  a  pain,  the  whole  movement  being  made  to  correspond 
with  the  natural  as  closely  as  possible. 

As  the  foetal  head  comes  under  the  arch  of  the  pubes  the  handles  of 
the  forceps  must  rise  more  aud  more  from  the  bed,  until  at  last  they  are 
over  the  abdomen  as  the  head  emerges  from  the  perineum.  This  last 
movement  of  instrumental  delivery  should  be  a  very  slow  one,  for  fear 
of  rupture.  It  has  been  proposed  to  remove  the  blades  before  delivery 
is  complete;  but  there  is  no  occasion  for  this  if  the  forceps  is  apjilied  to 
the  sides  of  the  head  over  the  parietal  protuberances,  as,  where  these 
protrude  aud  the  blades  are  flat  and  thin,  there  is  very  little  additional 
space  required.  With  such  instruments  as  the  old  Levret,  Baudelocque, 
and  Rohrer  forceps,  with  looped  or  kite-shaped  fenestra  and  thick  edges, 
this  was  a  much  more  imperative  direction  than  with  the  better  instru- 
ments of  the  present  day.  With  a  Sawyer  forceps  the  perineum  ought 
to  be  safer  and  under  better  control  than  without.  When  the  perineum 
is  thought  to  be  in  danger,  the  process  of  distension  should  be  retarded 
through  two  or  three  pains,  or  even  more  if  required,  instead  of  draw- 
ing the  head  through  at  once. 

After  the  head  is  delivered,  if  the  cord  is  not  around  the  neck  and 
therefore  in  danger  from  pressure,  the  body  should  be  allowed  to  remain 
until  the  uterus  has  well  contracted  upon  it,  for  fear  of  hemorrhage  after 
delivery,  from  uteriue  inertia. — Ed.] 


602 


OBSTETRIC  OPERATIONS. 


CHAPTER  IV. 


THE  VECTIS.— THE  FILLET. 


The  Vectis. — In  connection  ^vith  the  suliject  of  instrumental  deliv- 
ery it  is  essential  to  say  something  of  the  use  of  the  vectis,  on  account 
of  the  value  which  was  formerly  ascribed  to  it,  which  M^as  at  one  time 
so  great  in  England  that  it  became  the  favorite  instrument  in  the 
metropolis;  Denman  saying  of  it  that  even  those  who  employed  the  for- 
ceps were  "  very  willing  to  admit  the  equal,  if  not  superior,  utility  and 
convenience  of  the  vectis."  Even  at  the  present  day  there  are  practi- 
tioners of  no  small  experience  who  believe  it  to  be  of  occasional  great 
utility,  and  use  it  in  preference  to  the  forceps  in  cases  in  which  slight 
assistance  only  is  required.  In  spite,  hoAvever,  of  occasional  attempts  to 
recommend  its  use,  the  instrument  has  fallen  into  disfavor,  and  may  be 
said  to  be  practically  obsolete. 

Nature  of  the  Instrument. — The  vectis  in  its  most  approved  form 
consists  of  a  sin":le  blade,  not  unlike  that  of  a  short  straiy;ht 
Fig.  179.  forceps,  attached  to  a  Avooden  handle.  A  variety  of  modifica- 
tions exists  in  its  shape  and  size.  The  handle  has  been  occa- 
sionally manufactured,  for  the  convenience  of  carriage,  with  a 
hinge  close  to  the  commencement  of  the  blade  (Fig.  179)  or 
with  a  screw  at  the  point  where  the  handle  and  blade  join. 
The  poAver  of  the  instrument  and  the  facility  of  introduction 
depend  very  much  on  the  amount  of  curvature  of  the  blade. 
If  this  be  decided,  a  firmer  hold  of  the  head  is  taken  and 
greater  tractive  force  is  obtained,  but  the  difficulty  of  intro- 
duction is  increased. 

When  employed  in  the  former  way  the  fulcrum  is  intended 
to  be  the  hand  of  the  operator t;  but  the  risk  of  using  the 
maternal  structures  as  a  jMint  cVappvi,  and  the  inevitable  dan- 
ger of  contusion  and  laceration  whicli  nuist  follow,  constitute 
one  of  the  chief  objections  to  the  operation.)  Its  value  as  a 
tractor  must  always  be  limited  and  quite  inferior  to  that  of  the 
forceps,  while  it  is  as  difficult  to  introduce  and  mani))ulate. 
Cases  in  -which  it  is  Applicable, — The  vectis  has  been 
reconnncnded  in  cases  in  which  the  low  forceps  operation  is 
suitable,  provided  the  pains  have  not  entirely  ceased.  There  is  no 
doubt  that  it  may  be  quite  capable  of  overcoming  a  slight  impediment 
to  the  passage  of  the  head.  It  is  applied  over  various  parts  of  the 
head,  most  commonly  over  the  occiput,  in  the  same  manner,  and  with 
the  same  precautions,  as  one  blade  of  tlie  forceps.  Dr.  Ramsbotham 
says:  "We  shall  find  it  necessary  to  apply  it  to  different  parts  of  the 
cranium,  and  perhaps  the  face  also,  successively,  in  order  to  relieve  the 
liead  from  its  fixed  condition  and  favor  its  descent."     Such  an  opera- 


THE    VECTIS.—TITE  FILLET. 


503 


tion  obviously  requires  quite  as  mueh  dexterity  as  the  application  of 
the  forcejvi,  while,  if  we  bear  in  mind  its  comparatively  slight  power 
and  the  risk  of  injury  to  the  maternal  structures,  we  must  admit  that 
the  disuse  of  the  instrument  in  modern  practice  is  amply  justified. 

The  vectis  may,  however,  find  a  useful  application  when  employed 
to  rectify  malpositions,  especially  in  certain  occi  pi  to-posterior  presenta- 
tuTus.  Tills  action  of  the  instrument  has  already  been  considered 
(p.  325),  and  under  such  circumstances  it  may  prove  of  service  where 
the  forceps  is  inapplicable.  When  so  employed  it  is  passed  carefully 
over  the  occiput,  and  while  the  maternal  structures  are  guarded  from 
injury  downward  traction  is  made  during  the  continuance  of  a  pain. 
So  used,  its  application  is  perfectly  .simple  and  free  from  danger,  and 
for  this  purpose  it  may  be  retained  as  part  of  the  obstetric  armamen- 
tarium. 

The  Fillet  is  the  oldest  of  obstetric  instruments,  having  been  fre- 
quently employed  before  the  invention  of  the  forceps,  and  even  in 
the  time  of  Smellie  it  was  much  used  in  London.  It  has  since  com- 
pletely fallen  out  of  favor  as  a  scientific  instrument,  although  its  use  is 
every  now  and  again  advocated,  and  it  is  certainly  a  favorite  instru- 
ment with  some  practitioners.  This  is  to  be  explained  by  the  apparent 
simplicity  of  the  operation,  and  the  fact  that  it  can  generally  be  performed 
without  the  knowledge  of  the  patient.  The 
latter,  however,  is  one  strong  reason  why  it  Fig.  180. 

should  not  be  used. 

Nature  of  the  Instrument. — The  fillet 
consists,   in   its  most    improved    form    (that 
which  is  recommended  by  Dr.  Eardley  Wil- 
niot^)  (Fig.  180),  of  a   slip  of  whalebone 
fixed  into  a  handle  composed  of  two  sepa-    j 
rate  halves,  which  join  into  one.    The  whale-    I 
bone  loop  is  slipped  over  either  the  occiput    !; 
or  face,  and  traction  used  at  the  handle.        ; 

When  applied  over  the  face  after  the  head 
has  rotated,  it  would  probably  do  no  harm, 
but  if  it  were  so  placed  when  the  head  was 
high  in  the  pelvis,  traction  would  necessarily 
produce  extension  of  the  chin  before  the 
proper  time,  and  would  thus  interfere  with 
the  natural  mechanism  of  delivery.  If 
placed  over  the  occiput,  it  is  impossible  to 
make  traction  in  the  direction  of  the  pelvic 
axes,  as  the  instrument  will  then  infallibly 
slip.  If  traction  be  made  in  any  other  di- 
rection, there  must  be  a  risk  of  injuring  the  Wiimots  iiuet. 
maternal  structures  or  of  changing  the  posi- 
tion of  the  head.  Hence  there  is  every  reason  for  discarding  the  fillet 
as  a  tractor  or  as  a  substitute  for  the  forceps,  even  in  the  simplest 
cases. 

It  is  quite  possible  that  it  may  find  a  useful  application  in  certain 

'  06.^/.  Trans.,  1874,  vol.  xv.  p.  172. 


■ft) 


lit) 


504  OBSTETRIC  OPERATIONS. 

cases  ill  w  liicli  tlu'  vcotis  ni:iy  also  Ix'  used — vi/.  as  a  rectifier  of  lual- 
}K>sitioii,  and  i'roiu  the  (•(»iii|)aiativc  I'acility  of  its  introduction  it  would 
})robably  be  the  preferable  instrument  of  the  two. 


CHAPTER  y. 

OPEEATIONS  INVOLVING   DESTRUCTION   OF   THE   FCETUS. 

Operations  involving  the  destruction  and  mutilation  of  the 
child  were  amono;  the  first  practised  in  midwifery.  Craniotomy  was 
evidently  known  in  the  time  of  Hippocrates,  as  he  mentions  a  mcxle  oi" 
extracting  the  head  by  means  of  hooks.  Cclsus  describes  a  similar  oi)e- 
ration,  and  was  acquainted  with  the  manner  of  extracting  the  fa'tus  in 
trai>sverse  presentations  by  decapitation.  Similar  procedures  were  also 
practised  and  described  by  Aetius  and  others  among  the  ancient  writei's. 
The  physicians  of  the  Arabian  school  not  only  employed  perforators  for 
opening  the  liead,  but  were  acquainted  with  instruments  for  compressing 
and  extracting  it. 

Religious  Objections  to  Craniotomy. — Until  the  end  of  the  seven- 
teenth century  this  class  of  operation  was  not  considered  justifiable  in 
the  case  of  living  children  :  it  then  came  to  be  discussed  whether  the 
life  of  the  child  might  not  be  sacrificed  to  save  that  of  the  mother.  It 
was  authoi-itatively  ruled  by  the  Theological  Faculty  of  Paris  that  the 
destruction  of  the  child  in  any  case  was  mortal  sin :  "  Si  I'on  ne  ])eut 
tirer  I'enfant  sans  le  tucr,  on  ne  pent  sans  peche  niortel  le  tirer."  This 
dictum  of  the  Roman  Church  had  great  influence  on  continental  mid- 
Avifery,  more  especially  in  France,  where  uj)  to  a  recent  date  the  leading 
obstetricians  considered  craniotomy  to  be  only  justifiable  when  the  death 
of  the  foetus  had  been  positively  ascertained.  Even  at  the  ])reseut  day 
there  are  not  wanting  practitioners  who,  in  their  praiseworthy  objections 
to  the  destruction  of  a  living  child,  counsel  delay  until  the  child  has 
died — a  practice  thoroughly  illogical,  and  only  sparing  the  operator's 
feelings  at  the  cost  of  greatly  increased  risk  to  the  mother.  In  England 
the  safety  of  the  child  has  always  been  considered  subservient  to  that 
of  the  mother;  and  it  has  been  admitted  that  in  eveiy  case  in  wliich 
the  extraction  of  a  living  fa'tus  l)y  any  of  the  ordinary  means  is  impos- 
sible its  mutilation  is  perfectly  justifial)le. 

Formerly  Performed  with  Unjustifiable  Frequency. — It  must 
be  admitted  that  the  frequency  with  which  craniotomy  has  been  per- 
formed in  England  constitutes  a  great  blot  on  British  midwifery.  Dur- 
ing the  mastership  of  Dr.  I^abbat  at  the  Rotunda  Hospital  the  foiveps 
was  never  once  ajiplied  in  21,867  labors.  Even  in  the  time  of  Clarke 
and  Collins,  when  its  fVequeiicy  was  mucli  diniinishcd,  craniotomy  was 


OPERATIONS  INVOLVING  DESTRUCTION  OF  THE  FOETUS.  505 

performed  tliree  or  four  times  as  often  as  fore(,'ps  deliv^cry.  Tliese  fig- 
ures indieate  a  destruetion  of  foetal  life  which  wc  cannot  look  back  to 
without  a  shudder,  and  which,  it  is  to  be  feared,  justify  the  reproaches 
which  our  continental  brethren  have  cast  upon  our  practice.  Fortu- 
nately, professional  opinion  has  now  completely  recognized  the  sacred 
duty  of  saving  the  infant's  life  whenever  it  is  practicable  to  do  so;  and 
British  obstetricians  now  teach  as  carefully  as  those  of  any  other  nation 
the  imperative  necessity  of  using  every  endeavor  to  avoid  the  destruc- 
tion of  the  foetus. 

Divisions  of  the  Subject. — The  operation  now  under  consideration 
may  be  necessary — 1st,  when  the  head  requires  either  to  be  simply  per- 
forated or  afterward  more  completely  broken  up  and  extracted — an  ope- 
ration which  has  received  various  names,  but  is  generally  known  in 
England  as  craniotomy,  and  which  may  or  may  not  require  to  be  fol- 
lowed by  further  diminution  of  the  trunk  ;  2dly,  when  the  arm  presents 
and  turning  is  impossible :  this  necessitates  one  of  two  procedures — 
decapitation,  with  the  separate  extraction  of  the  body  and  head,  or  evis- 
ceration. [Or,  what  is  equally  promising  in  such  cases,  where  the 
w^oman  has  had  no  deforming  disease  and  is  far  less  difficfdt  of  execu- 
tion, the  conservative  Cesarean  section. — Ed.]  In  both  classes  of  cases 
similar  instruments  are  employed,  and  those  generally  in  use  at  the  pres- 
ent time  may  be  first  briefly  described. 

Instruments  Employed. — 1.  The  object  of  the  perforator  is  to 
pierce  the  skull  of  the  child,  so  as  to  admit  of  the  brain  being  broken 
up  and  the  consequent  collapse  and  diminution  in  size  of  the  cranium. 
The  perforator  invented  by  Denman  or  some  modification  of  it  has  been 


Fig.  181. 


Fig.  182. 


Fig.  183. 


Various  Forms  of  Perforators. 


principally  employed.  It  requires  the  handles  to  be  separated  in  order 
to  open  the  blades,  and  this  cannot  be  done  by  the  operator  himself. 
This  difficulty  is  overcome  in  the  modification  of  Naegele's  perforator 


506 


OBSTETRIC  OPERA  TIONS. 


used  in  Edinhurgli,  in  wliidi  the  handles  jire  so  constructed  that  th<y 
ojjen  the  points  when  pressed  together,  and  are  separated  by  a  steel  rt>d 
with  a  joint  at  its  centre  to  prevent  their  opening  too  soon.  By  tiiis 
arrangement  the  instrument  can  be  manipulated  by  one  hand  only.  The 
sharp-pointed  portion  has  an  external  cutting  edge,  with  projecting 
shoulders  at  its  base  to  prevent  its  penetrating  too  I'ar  into  the  cranium. 
Many  modifications  of  these  arrangements  have  since  been  contrived 
(Figs.  181,  182,  183).  In  some  parts  of  the  Continent  a  perforator  is 
used  constructed  on  the  principle  of  the  trephine,  but  this  is  vastly 
more  difficult  to  work,  and  has  the  great  disadvantage  of  simply  boring 
a  hole  in  the  skull,  instead  of  splitting  it  up  as  is  done  by  the  shai'p- 
pointed  instrument. 

Crotchets  and  Craniotomy  Forceps. — The  instruments  for  extrac- 
tion are  the  crotchet  and  craniotomy  forceps. 

The  crotchet  is  a  sharp-pointed  hook  of  highly-tempered  steel  which 
can  be  fixed  on  some  portion  of  the  skull,  either  internal  or  external, 
traction  being  made  by  the  handle.  The  shank  of  the  instrument  is 
either  straight  or  curved  (Figs.  184  and  185),  the  latter  l)eing  prefer- 
able, and  it  is  either  attached  to  a  wooden  handle  or 
Figs.  184, 185.  forged  in  a  single  piece  of  metal.  A  modification  ot" 
^Ijv  this  instrument  is  known  as  Oldham's  vertebral  hook. 

VlX  It  consists  of  a  slender  hook,  measuring  with  its  han- 

\\  die  13  inches  in  length,  which  is  passed  through  the 

foramen  magnum  and  fixed  in  the  vertebral  canal,  so 
as  to  secure  a  firm  hold  lor  traction.  {  X\\  forms  of 
crotchets  are  open  to  the  serious  objection  of  being 
liable  to  slip  or  break  through  the  bone  to  which  they 
are  fixed,  so  wounding  either  the  soft  parts  of  the 
mother  or  the  fingers  of  the  operator  placed  as  a 
guard.)  Hence  they  are  discountenanced  by  most  re- 
cent wi'iters,  and  may  with  propriety  be  regarded  as 
obsolete  instruments. 

Their  place  as  tractors  is  well  supplied  by  the  more 
modern  craniotomy  forceps  (Fig.  186).  These  are 
intended  to  lay  hold  of  the  skull,  one  blade  being 
introduced  within  the  cranium,  the  other  externally, 
and  when  a  firm  grasp  has  been  obtained  downward 
traction  is  made.  \A.  second  object  it  fulfils  is  to 
%J)  break  away  and  remove  portions  of  the  skull  when 
j>pi-f oration  and  traction  alone  are  insufficient  to  efiect 
delivery.  )  jNIany  forms  of  craniotomy  forcejis  are  in 
use — some  armed  with  formidable  teeth  ;  others,  of 
simpler  construction,  depending  on  their  roughened 
Crotchets.  and  Serrated  internal  surfaces  for  firnnie.ss  of  grasp. 

For  general  use  there  is  no  better  in.strument  than 
the  cranioclast  of  Sir  James  Simpson  (Fig.  187),  which  admiral)ly  ful- 
fils both  these  indications.  It  consists  of  two  .separate  blades  fastened 
by  a  button  joint.  The  extremities  of  the  blades  are  of  a  duck-l)illed 
shape,  and  are  sufficiently  curved  to  allow  of  a  firm  gra.-^p  of  the  skull 
being  taken  :  the  upper  blade  is  deeply  grooved  to  allow  the  lower  to 


OPERATIONS  IXVOLVIXG  DESTRUCTION  OF  THE  FCETUS.   507 

sink  into  it,  and  this  gives  the  instrument  great  power  in  fracturing  tlie 
cranial  bones  when  that  is  found  to  be  necessary.  It  need  n(jt,  how- 
ever, be  employed  for  the  latter  purpose,  and,  the  blades  being  serrated 
on  their  under  surface,  form  as  perfect  a  pair  of  craniotomy  forceps  as 


Fig.  186. 


Fig.  187. 


Craniotomy  Forceps. 


Simpson's  f'ranioclast. 


any  in  ordinary  use.     Provided  with  it,  we  are  spared  the  necessity  of 
procuring  a  number  of  instruments  for  extraction. 

Cephalotribe. — Amongst  modern  improvements  in  midwifery  there 
are  few  which  have  led  to  more  discussion  than  the  use  of  the  cephalo- 
tribe. This  instrument,  originally  invented  by  Baudelocque,  was  long 
eraploved  on  the  Continent  before  it  was  used  in  Great  Britain,  the  prej- 
udice against  it  being  no  doubt  due  to  its  formidable  size  and  appear- 
ance. Of  late  years  many  of  our  leading  obstetricians  have  used  it  in 
preference  either  to  the  crotchet  or  craniotomy  forceps,  and  have  materi- 
ally modified  and  improved  its  construction,  so  that  the  most  objection- 
able features  of  the  older  instrument  are  now  entirely  removed. 

The  Instrument. — ^The  cephalotribe  consists  of  two  powerful  solid 
blades  which  are  applied  to  the  head  after  perforation  and  approximated 
by  means  of  a  screw  so  as  to  crush  the  cranial  bones,  and  after  this  it 
may  be  also  used  for  extraction.)  The  peculiar  value  of  the  instrument 
is  that  w4ien  properly  applied  it  crushes  the  firm  base  of  tlie  skull, 
wdiich  is  left  untouched  by  craniotomy,  or  if  it  does  not  it  at  least  causes 
the  base  to  turn  edgeways  within  the  blades,  so  as  to  be  in  a  more  favor- 
able position  for  extraction.  Another  and  specially  valuable  property 
is  that  it  crushes  the  bones  within  the  scalp,  which  forms  a  most  efficient 
protective  covering  to  their  sharp  edges.  In  this  way  one  of  the  prin- 
cipal dangers  of  craniotomy — the  wounding  of  the  maternal  passages 
bv  spiculse  of  l)one — is  entirely  avoided. 

The  cephalotribe,  therefore,  acts  in  two  ways — as  a  crusher  and  as  a 


608 


OBSTETRIC  OPERA  TIONS. 


tractor.     Some  ol).<tetricians  believe  the  iunnei-  to  be  its  inorc  iiii|)(irtant 

use,  and  even  maintain  tliat  tlie  eeplialo- 
FiG.  188.  tribe  is  unsuited  fur  traction.    Tliisview 

is  specially  maintained  by  Pajot,  who 
teaches  that  alter  the  size  of  the  skull 
has  J)een  diminished  by  r('j)eated  criisii- 
ing'S  its  exjnilsioii  should  be  left  to  the 
natural  powers.  There  are  some  grounds 
for  believing  tliat  in  the  greater  degrees 
of  obstruction  the  tractile  j)Ower  of  the 
instrument  should  not  be  called  into 
use,  but  in  the  large  majority  of  cases 
the  facility  with  which  the  crushed  head 
may  be  withdrawn  by  it  constitutes  one 
of  its  chief  claims  to  the  attention  of 
the  obstetrician,  f  No  one  who  has  used 
it  in  this  way,  and  experienced  the  raj)id 
and  easy  manner  in  which  it  accom- 
plishes delivery,  can  have  any  doubt 
on  this  point.  "^ 

There  is  every  reason  to  believe  that 
cephalotripsy  will  be  much  extended  in 
Great  Britain,  and  that  it  will  be  con- 
sidered, as  I  believe  it  un{juestional)ly 
deserves  to  be,  tlie  ordinary  operation  in 
cases  requiring  destruction  of  the  fcetus. 
The  comparative  merits  of  ce])halotripsy 
and  craniotomy  will  be  subsequently 
considered. 

The  most  perfect  cephalotribe  is  prob- 
ably that  known  as  Braxton  Hicks' 
(Fig.  188),  which  is  a  modification  of 
Simpson's.  It  is  not  of  unwieldy  size,  but  sufficiently  powerful  for  any 
case,  and  not  extravagant  in  price.  The  blades  liave  a  slight  pelvic 
curve,  which  materially  facilitates  their  introduction,  yet  not  sufHcicntly 
marked  to  interfere  with  their  being  slightly  rotated  after  apjilication. 
Dr.  Kidd  of  Dublin  prefers  a  straight  blade,  while  Dr.  Matthews  Dun- 
can thinks  it  better  to  use  a  somewhat  bulkier  instrument,  modelled  on 
the  type  of  the  continental  cephalotribes.  The  principle  of  action  of 
all  these  is  identical,  and  their  diU'erences  are  not  of  very  material 
im]X)rtance. 

Section  of  the  Skull  by  the  Forceps  Saw  or  Ecraseur. — An- 
other mode  of  diminishing  the  foetal  skull  is  by  removing  it  in  sections. 
The  object  is  aimed  at  in  the  forcej)f<  •'^■«m"  of  A'^an  Huevel,  which  con- 
sists of  two  large  blades,  not  unlike  those  of  the  cephalotribe  in  appear- 
ance. Within  these  there  is  a  complicated  mechanism  working  a  chain- 
saw  from  below  upward,  Avhich  cuts  through  the  fVetal  skull ;  the  sep- 
arated ])ortions  are  subsequently  withdrawn  piecemeal.  This  instrument 
is  highly  spoken  of  by  the  Belgian  obstetricians,  who  beli(!ve  that  it 
affords  by  far  the  safest  and  most  effectual  way  of  reducing  the  bulk  of 


Hicks'  Cephalotribe. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  THE  F(ETUS.   509 

the  foetal  .skull.  In  England  it  is  practically  unknown,  and,  although 
it  must  be  admitted  to  be  theoretically  excellent,  the  complexity  and  cost 
of  the  apparatus  have  always  stood  in  the  way  of  its  l>eing  used. 

Dr.  Barnes  has  suggested  that  the  same  results  may  be  obtained  by 
dividing  the  head  with  a  strong  wire  ecraseur.  So  far  as  I  know,  this 
suggestion  has  never  yet  been  carried  out  in  practice,  not  even  by  him- 
self, and  therefore  it  is  not  possible  to  say  much  about  it.  I  should 
imagine,  however,  that  there  would  be  considerable  difficulty  in  satis- 
factorily passing  the  loop  of  wire  over  the  skull  in  a  pelvis  in  which 
there  is  any  well-marked  deformity. 

Cases  requiring-  Craniotomy. -iThe  most  common  cause  for  which 
craniotomy  or  cephalotripsy  is  performed  is  a  want  of  proper  proportion 
between  the  head  and  the  maternal  passages.)  This  may  arise  from  a 
variety  of  causes.  The  most  important,  and  tliat  most  often  necessitat- 
ing the  operation,  is  osseous  dQigrmity.  This  may  exist  either  in  the 
brim,  cavity,  or  outlet,  and  it  is  most  often  met  wdth  in  the  antero- 
posterior diameter  of  the  brim.  Obstetric  authorities  differ  consider- 
ably as  to  the  precise  amount  of  contraction  which  will  prevent  the 
passage  of  a  living  child  at  term.  Thus,  Clarke  and  Burns  believe 
that  a  living  child  cannot  pass  through  a  pelvis  in  which  the  antero- 
posterior diameter  at  the  brim  is  less  than  3j  inches.  Ramsbotham 
iixes  the  limit  at  3  inches,  and  Osborne  and'  Hamilton  at  2|_inches. 
(The  latter  is  the  extreme  limit  at  which  the  birth  of  a  living  child  is 
possible  ^  but  there  can  be  no  doubt  that  under  favorable  circumstances 
it  may  be  possible  to  draw  the  foetus,  after  turning,  through  a  pelvis  of 
that  size.  The  opposite  limit  of  the  ojjeratiou  is  still  more  open  to  dis- 
cussion. Various  authorities  have  considered  it  quite  possible  to  draw 
a  mutilated  foetus  through  a  pelvis  in  which  the  antero-posterior  diam- 
eter does  not  exceed  1^  inches,  and  indeed  have  succeeded  in  doing  so, 
/But  then  there  must  be  a  fair  amount  of  space  in  the  transverse  diam- 
\eter  of  the  pelvis  to  admit  of  the  necessary  manipulations.  If  there 
be  a  clear  space  here  of  3  inches  and  upward,  it  is  no  doubt  possible  to 
deliver  per  vias  naturales  ;  but  in  such  extreme  deformities  the  difficul- 
ties are  so  great,  and  the  bruising  of  the  maternal  structures  so  exten- 
sive, that  it  becomes  an  operation  of  the  greatest  possible  severity,  with 
results  nearly  as  unfavorable  to  the  mother  as  the  Csesarean  section. 
Hence  some  continental  authorities  liave  not  scrupled  to  prefer  the  latter 
operation  in  the  worst  forms  of  pelvic  deformity.  The  rule  in  English 
practice  always  has  been  that  craniotomy  must  be  performed  whenever 
it  is  practicable  and  there  can  be  no  doubt  that  it  is  the  right  one. 
<  Between  from  2f  to  3  inches  antero-posterior  diameter  in  the  one 
(direction.  If  inches  in  the  other,  may  be  said  to  be  the  limits  of  crani- 
iotomy,  provided,  in  the  latter  case,  there  be  a  fair  amount  of  space  in 
^the  transverse  diameter.  The  same  limits  may  be  laid  down  with  regard 
to  tumors  or  other  sources  of  obstruction. 

There  are  a  few  other  conditions  in  which  craniotomy  is  justifiable, 
independently  of  pelvic  contraction,  such  as  certain  changes  in  the 
soft  parts  which  are  supposed  to  render  the  passage  of  the  head  peculiarly 
dangerous  to  the  mother.  Among  them  may  be  mentioned  swelling 
and  inflammation  of  the  vagina  from  the  length  of  the  previous  labor, 


510  OBSTETRIC  OPERATIONS. 

bands  and  ciciUxk:*^ i>t  tlic  vaiiiiia,  and  occlusiuii  anil  rigidity  ol'  the  o.s. 
Jt  is  hardly  too  niiich  to  say  that  with  a  proper  use  of  the  resources^oT 
niidwit'ery  the  destruction  of  a  livinjj;  fetus  for  any  of  these  conditions 
may  be  obviated.  'J'hc  most  common  of  them  is  undoubtedly  s\vcllin<i:; 
>  of  the  soft  parts,  causint;-  impaction  of  the  head — an  occurrence  winc-h 
i  ought  to  be  invariably  prevented  by  a  tiiuely  use  of  the  forceps.  .Should 
interference  unfortunately  be  delayed  until  impaction  has  actually  taken 
place,  doubtless  n<j  other  resource  but  craniotomy  would  be  loft ;  but 
such  cases,  it  is  to  be  hoped,  are  now  of  rare  occurrence  in  Jiritish  prac- 
tice. Undue  rigidity  of  the  os  can  be  overcome  by  dilatation  with  the 
caoutchouc  bags,  or  in  more  serious  cases  by  incision,  which  would  cer- 
tainly be  less  perilous  to  the  mother  than  dragging  even  a  nuitilatcd 
fa3tus  through  the  small  and  rigid  aperture.  In  the  case  of  bands  and 
cicatrices  iu  the  vagina,  dilatation  or  incision  will  generally  suffice  to 
remove  the  obstruction ;  but  even  were  this  not  so,  here,  as  in  excessive 
rigidity  of  the  perineum,  it  would  be  better  that  slight  lacei-ations  should 
take  place  than  that  the  cliild  should  be  killed. 

Certain  complications  of  labor  are  held  to  justify  craniotomy, 
such  as  rujjture  of  the__ute.rus,  convulsions,  and  hemorrhage.  The 
application  of  tlieTorceps  or  turning  will  generally  answer  our  purpose 
equally  well,  especially  as  we  have  the  means  of  dilating  the  os  suffici- 
ently to  admit  of  one  or  other  of  them  being  performed  when  the  natural 
dilatation  is  not  sufficient.  Craniotomy  in  rupture  of  the  uterus  will 
also  be  rarely  indicated,  as  we  have  seen  that  gastrotomy  apjicars  to 
afford  a  better  chance  to  the  mother  in  those  cases  in  which  the  foetus 
has  partially  or  entirely  escaped  from  the  uterine  cavity. 

Want  of  proportion  betMecu  the  foetUvS^aiid  the. pelvis,  depending  on 
luidue  size  of  the  head,  either  natural  or  the  result  of  disease,  may 
render  the  operation  essential.  In  the  former  of  these  cases  we  shall 
generally  have  first  attempted  delivery  with  the  forceps,  and  if  it  has 
failed,  there  can  be  no  doubt  as  to  the  propriety  of  lessening  the  bulk 
of  the  head  by  perforation. 

( In  most  obstetric  works  we  are  recommended  to  perforate  rather  than 
\apply  the  forceps  when  Ave  are  convinced  that  the  child  has  ceased  to 
IVixcJ  This  advice  is  based  on  the  greater  facility  with  Avhich  craniotomy 
can  be  performed,  and  its  supposed  greater  safety  to  the  mother.  There 
can  be  no  doubt  of  the  ease  with  which  the  child  can  be  extracted  after 
perforation  when  the  pelvis  is  not  contracted,  and  if  we  could  always 
be  sure  of  our  diagnosis,  the  rule  might  l)e  a  good  one.  Before  acting 
on  it,  however,  we  nuist  bear  in  mind  the  extreme  difficulty  of  posi- 
tively ascertaining  the  death  of  the  i'o?tus.  Of  the  signs  usually  relied 
on  for  this  purpose,  there  are  scarcely  any  whicli  are  not  open  to  fallacy, 
except  peeling  of  the  scalp  and  disintegration  of  the  cranial  bones,  which 
do  not  take  place  unless  the  child  has  been  dead  for  a  length  of  time, 
and  are  therefore  useless  in  most  instances.  Discharge  of  the  meconium 
constantly  takes  jilace  Avhen  the  child  is  alive;  a  cold  and  jndsclcss  pro- 
lapsed cord  may  belong  to  a  twin  ;  and  a  fetal  heart  may  become 
temporarily  inaudible  although  the  child  is  not  dead.  If,  indeed,  we 
have  carefully  watched  the  fetal  heart  all  through  the  labor,  and  heard 
it  become  more  and  more  feeble,  and  finally  stop  altogether,  we  might 


OPERATIONS  INVOLVING  DESTRUCTION  OF  THE  FOETUS.  511 

be  cerlaiu  that  the  child  lias  died  ;  but  surely  such  observations  would 
rather  indicate  an  early  recourse  tqthe  forceps  or  version  so  as  to  obviate 
the  tatal  result  we  know  to  be  ini])endin<i;. 

Perforation  of  the  After-coming"  Head. — In  certain  breech  i)res- 
entations  or  after  turning  it  may  be  found  impossible  to  extract  the 
head  without  diminishing  its  size  by  perforating  behind  _tjig,^r.  In 
such  cases  we  know  to  a  certainty  whether  the  child  be  alive  or  dead 
before  resorting  to  the   operation. 

The  first  step,  whether  we  resort  to  cephalotripsy  or  craniotomy,  is 
])erforation,  which  will  therefore  be  first  described.  In  the  former  the 
<lesirability  of  first  perforating  the  head  is  not  always  recognized.  To 
endeavor  to  crush  the  head  without  perforating  is  needlessly  to  increase 
the  difficulties  of  the  case,  and  Tit  should  be  remembered  as  a  cardinal 
rule  that  perforation  is  an  essential  preliminary  to  the  proper  use  of 
the  cephalotribe.^ 

Before  perforating  we  must  carefully  ascertain  the  exact  relation  of 
the  OS  to  the  presenting  part,  since  in  many  cases  the  operation  is  per- 
formed before  the  os  is  fully  dilated,  when  there  is  a  risk  of  wounding 

Fig.  189. 


Perforation  of  the  Skull. 


the  cervix.  Two  or  more  fingers  of  the  left  hand  should  be  passed  up 
to  the  head,  and  placed  against  the  most  prominent  part  of  the  parietal 
bone.     Under  these,  used  as  a  guard  (Fig.  189),  the  perforator  sliould 


512  OBSTETRIC  OPERATIONS. 

be  oautiously  intnxliuctl  until  the  scalp  is  readied.  (It  is  iinportaut  to 
\fix  on  a  bony  part  of  the  skull,  ancLnot  on  a  suture  or  fontanelle,  for 
|j)uncture|  because  our  object  is  to  break  up  the  vault  of  the  cranium  as 
^nud)  as  ])()ssiblc,  so  as  to  allow  the  skull  to  collapse.  When  the  instru- 
ment has  reached  the  point  we  have  selected,  it  should  be  made  to  pene- 
trate the  scalp  and  skull  with  a  s^ii-rotatory  burin<^  motion,  and 
advanced  until  it  has  suuk  up  to  the  rests,  which  will  oppose  its  far- 
ther progress.  Occasionally  considerable  force  w\\\  be  necessary  to 
ellect  jienetration,  more  especially  if  the  scalp  be  swollen  by  long- 
continued  pressure;  aud  this  stage  of  the  o])erati(jn  will  be  facilitated 
by  causing  an  assistant  to  steady  the  head  by  pressure  on  the  fo'tus 
through  the  aJKlomen,  more  especially  if  it  be  still  free  above  the 
pelvic  brim.  ^\  e  must  then  press  together  the  handles  of  the  instru- 
ment, which  will  have  the  effect  of  widely  separating  the  cutting 
portion  and  making  an  incision  tlirough  the  bones.  After  this  the 
j)oint  should  be  turned  round,  and  again  opened  at  right  angles  to 
the  former  incision,  so  as  to  make  a  free  crucial  opening.  During  this 
process  care  must  be  taken  to  bury  the  perforator  in  the  skull  up  to  the 
rests,  so  as  to  avoid  the  possibility  of  injuring  the  maternal  soft  parts. 
The  instrument  should  now  be  introduced  within  the  skull  and  moved 
freely  about,  so  as  to  thoroughly  and  completely  break  uj)  the  bi-ain. 
Especial  care  must  be  taken  to  reach  the  medulla  oblongata  and  base 
of  the  brain,  for  if  these  are  not  destroyed  we  may  subject  ourselves 
I  to  the  distress  of  extracting  a  child  in  whom  life  was  not  extinct.  If 
this  part  of  the  operation  be  thoroughly  performed,  there  will  be  no 
necessity  for  washing  out  the  brain  by  the  injection  of  warm  water,  as 
is  sometimes  recommended,  for  the  broken-up  tissue  W'ill  escape  freely 
through  the  opening  made  by  the  perforator. 

The  perforation  of  the  after-coming  head  does  not  generally  offer  any 
particular  difficulty.  It  is  accomplished  in  the  same  manner,  the  child's 
body  being  well  drawn  out  of  the  way  by  an  assistant.  The  point  of 
the  perforator,  carefully  guarded  by  the  finger,  is  guided  up  to  the  occi- 
put or  behind  the  ear,  Mhere  it  is  inserted. 

If  there  be  no  necessity  for  very  rapid  delivery,  and  the  pains  be  still 
present,  it  is  often  advisable  to  wait  ten  minutes  or  a  quarter  of  an  hour 
before  proceeding  to  extract.  This  delay  will  allow  the  skull  to  collajise 
and  become  moulded  to  the  cavity  of  the  pelvis  when  forced  down  by 
the  pains,  and  possibly  the  natural  efforts  may  suffice  to  finish  the  labor 
in  that  time ;  or  at  least  the  head  will  have  descended  farther  and  will 
be  in  a  better  position  for  extraction.  Should  jierforation  be  required 
after  having  ftiilcd  to  deliver  with  the  forceps — and  this  is  mdy  likely 
to  be  the  case  when  the  obstruction  is  comparatively  slight-Hit  is  cer- 
tainly a  good  plan  to  perforate  without  removing  the  forceps,  which 
may  then  be  used  as  a  tractor.! 

We  have  now^  to  decide  on  thfe  method  of  extraction,  and  our  choice 
generally  lies  between  the  cephaloti-ibe  and  the  craniotomy  forcejis, 
although  in  some  few  cases,  in  which  the  j)elvic  contraction  is  slight, 
version  may  be  advantageously  emjdoyed.  - 

Comparative  Merits  of  Cephalotripsy  and  Craniotomy.— \Those 
who  have  used  both  must,  I  think,  admit  that  in  any  ordinary  case,  iu 


OPERATIONS  INVOLVING  DESTRUCTION  OE  THE  FCETUS.  513 

which  the  obstruction  i.s  not  <^reut  und  only  a  comparatively  slight 
diminution  in  the  size  of  the  head  is  required,  cephalotripsy  is  infinitely 
the  easier  operation.  )  The  facility  with  which  the  skull  can  be  crushed 
is  sometimes  remarkable,  and  those  who  will  take  the  trouble  to  read 
the  re])orts  of  the  operation  published  ]>y  Braxton  Hicks,  Kidd,  and 
others  cannot  fail  to  be  struck  with  the  rapidity  with  wliich  the  broken- 
down  head  may  often  be  extracted.  This  is  far  from  being  the  case  with 
the  craniotomy  forceps,  even  when  the  obstruction  is  moderate  only ;  for 
it  may  be  necessary  to  use  considerable  traction,  or  the  blades  may  take 
a  proper  grasp  with  difficulty,  or  it  may  be  essential  to  break  down  and 
remove  a  considerable  jwrtion  of  the  vault  of  the  cranium  before  the 
head  is  lessened  sufficiently  to  pass.  During  the  latter  process,  how- 
ever carefully  performed,  there  is  a  certain  risk  of  injuring  the  mater- 
nal structures,  and  in  the  hands  of  a  nervous  or  inexperienced  operator 
this  danger,  which  is  entirely  avoided  in  cephalotripsy,  is  far  from  slight. 
The  passage  of  the  blades  of  the  cephalotribe  is  by  no  means  difficult, 
and  I  think  it  must  be  admitted  that  the  possible  risks  attending  it  are_ 
comparatively  small.  (  On  account,  therefore,  of  its  simplicity  and  safet} 
to  the  maternal  structures,  I  believe  cephalotripsy  to  be  decidedly  the 
preferable  operation  in  all  cases  of  moderate  obstruction.  ) 

When  we  approach  the  lower  limit  and  have  to  do  with  a  ver 
marked  amount  of  pelvic  deformity,  the  two  operations  stand  on  a  more 
equal  footing.  Then  the  deformity  may  be  so  great  as  to  render  it  dif- 
ficult to  pass  the  blades  of  even  the  smallest  cephalotribe  sufficiently 
deep  to  grasp  the  head  firmly,  and  even  when  they  are  passed  the  space 
is  often  so  limited  as  to  impede  the  easy  working  of  the  instrument. 
Besides  this,  repeated  crushings  may  be  required  to  diminish  the  skull 
sufficiently.  I  attach  but  little  importance  to  the  argument  that  the 
diminution  of  the  skull  in  one  diameter  increases  its  bulk  in  another. 
LThe  necessity  of  removing  and  replacing  the  blades  on  another  part  of 
the  skull,  and  of  repeating  this  perhaps  several  times,  in  the  manner 
recommended  by  Pajot,  is  a  far  more  serious  objection^  To  do  this  in 
a  contracted  pelvis  involves,  of  necessity,  the  risk  of  much  contusion. 
Fortunately,  cases  of  this  kind  are  of  extreme  rarity,  much  more  so  than 
is  generally  believed,  but  when  they  do  occur  they  tax  the  resources  of 
the  practitioner  to  the  utmost. 

On  the  whole,  the  conclusion  I  would  be  inclined  to  arrive  at  with\ 
regard  to  the  two  operations  is  that  in  all  ordinary  cases  cephalotripsy  V 
is  safer  and  easier,!  whereas  in  cases  with  considerable  pelvic  deformity  I 
the  advantages  of  cephalotripsy  are  not  so  Avell  marked,  and  craniotomy  \ 
mav  even  prove  to  be  preferable.  \ 

(The  first  step  in  using'tKe  cephalotribe  is  the  passage  of  the  blades. 
These  are  to  be  inserted  in  precisely  the  same  manner  and  with  the  same 
precautions  as  in  the  high-forceps  operation.)  In  many  cases  the  os  is 
not  fully  dilated,  and  it  is  absokitely  essential  to  pass  the  instrument 
within  it.  Special  care  should  therefore  be  taken  to  avoid  any  injury 
to  its  edges,  and  for  this  ]uirpose  two  or  three  fingers  of  the  left  hand, 
or  even  the  whole  hand,  should  be  passed  high  up,  so  as  thoroughly  to 
protect  the  maternal  structures,  (in  order  that  the  base  of  the  skull  may. 
be  reached  and  eflFectually  crushed  the  blades  must  be  deeply  inserted/ 

33 


514 


OBSTETRIC  OPERATIONS. 


and  in  cluing  this  groat  care  and  geiitlcnf.ss  must  be  used.  As  the  pro- 
jecting promontory  of  the  sacrum  generally  tilts  the  head  forward,  the 
handles  of  the  instrument,  after  locking,  must  be  ■well  pressed  back- 
■ward  toward  the  })erineum.  \If  the  blades  do  not  lock  easily  or  if  any 
obstruction  to  their  passage  be  experienced,  one  of  them  nuist  be  with- 
drawn and  reintroduced,  just  as  in  forceps  operations.  )  Care  must  be 
taken,  as  tiie  instrument  is  being  inserted,  to  fix  and  steady  tlie  head 
by_abdoininal  pressure,  since  it  is  generally  far  above  the  brrm,  and 
would  readily  recede  if  this  precaution  were  neglected.  AA'heu  tiie 
blades  are  in  situ  we  proceed  to  crush  by  turning  the  screw  sktwly,  and 
as  the  blades  are  approximated  the  bones  yield  and  the  ce])halotribe 
sinks  into  the  cranium.  The  crushed  portion  then  measures,  of  course, 
no  more  than  the  thickness  of  the  blades,  that  is,  about  1-^  inches. 
This  is  necessarily  accompanied  by  some  bulging  of  the  part  of  the 
cranium  that  is  not  within  the  grasp  of  the  instrument  (Fig.  190),  but 
in  slight  deformity  this  is  of  no  consequence,  and  Me  may  proceed  to 
extraction,  waiting,  if  possible,  for  a  pain,  and  drawing  at  first  down- 
ward in  the  axis  of  the  pelvic  inlet,  as  in  forceps  delivery,  then  in  the 

axis  of  the  outlet.  The  site  of  perforation 
should  be  examined  to  see  that  no  spicuke 
of  bone  are  projecting  from  it,  and  if  so  they 
should  be  carefully  removed.  In  such  cases 
the  head  often  descends  at  once  and  with  the 
greatest  ease.  Should  it  not  do  so  or  should 
the  obstruction  be  considerable,  a  quarter 
turn  should  be  given  to  the  handles  of  the 
instrument,  so  as  to  bring  the  crushed  por- 
tion into  the  narrower  diameter  and  the 
uncrushed  portion  into  the  wider  transvei'se 
diameter.  It  may  now  be  advisable  to  re- 
move the  blades  carefully,  and  to  reintro- 
duce them  with  tlie  same  precautions,  so  as 
to  crush  the  unbroken  portion  of  the  skull. 
This  adds  materially  to  the  difficulties  of  the 
case,  since  the  blades  have  a  tendency  to  fall 
into  the  deep  channel  already  made  in  the 
cranium,  and  so  it  is  b}-  no  means  always 
easy  to  seize  the  skull  in  a  new  direction. 
Before  reapplying  them,  if  the  condition  of 
the  patient  be  good  and  ]iains  be  present,  it 
may  be  well  to  wait  an  liour  or  more,  in  the 
hope  of  the  head  being  moukled  and  pushed 
down  into  the  pelvic  cavity.  I  This  was  the 
plan  adopted  by  Dubois,  and,  according  to 
Tarnier,  was  the  secret  of  iiis  great  success 
in  the  operation.  Pajot's  method  of  repeated 
crushing  in  the  greater  degrees  of  contrac- 
tion is  based  on  the  same  idea,  and  he  recom- 
mends that  the  instrument  should  be  intro- 
duced at  intervals  of  two,  three,  or  four  hours,  according  to  the  state  of 


Foetal  Heart  Crushed  by  the 
Cephalotribe. 


OPEB.ATIONS  INVOLVING  DESTRUCTION  OF  THE  FCETUS.  515 


Fig.  191. 


the  patient,  until  the  head  is  thoroughly  crushed,  no  attempts  at  traction 
being  used  and  expulsion  being  left  to  the  natural  powers.  This,  he 
says,  should  always  be  done  when  the  contraction  is  below  2}  inches, 
and  he  maintains  that  it  is  quite  possible  to  effect  delivery  by  this  means 
when  there  are  only  1|  inches  in  the  antero-posterior  diameter.  The 
repeated  introduction  of  the  blades  in  this  fashion  must  necessarily  be 
hazardous,  except  in  the  hands  of  a  very  skilful  operatoi- ;  and  I  believe 
that  if  a  second  application  foil  to  overcome  the  difficulty,  which  will 
only  be  very  exceptionally  the  case,  it  would  be  better  to  resort  to  the 
measures  presently  to  be  described. 

Professor  Simpson  of  Edinburgh  ^  has  recently  suggested  the  use  of 
an  instrument  which  he  calls  a  "  basilyst."  Its  object  is  to  break  up 
the  base  of  the  foetal  skull  from  witRTn^  after  the  method 
originally  proposed  by  Guyon.  The  screw-like  portion 
of  the  instrument  (Fig.  191),  which  is  inserted  through 
the  perforation  made  in  the  cranial  vault,  is  driven 
through  the  hard  base,  which  is  then  disintegrated  by 
the  separate  movable  blade.  If  experience  proves  that 
this  instrument  can  be  readily  worked,  it  promises  to 
be  a  valuable  addition  to  our  armamentarium,  since  it 
will  effectually  destroy  the  most  resistant  ^^ortion  of  the 
skull  without  risk  of  injury  to  the  maternal  structures, 
and  thus  very  materially  facilitate  extraction. 

Extraction  by  the  Craniotomy  Forceps. — Should 
we  elect  to  trust  to  the  craniotomy  forceps  for  extraction, 
one  blade  is  to  be  introduced  through  the  perforation, 
and  the  other,  in  apposition  to  it,  on  the  outside  of  the 
scalp.  In  moderate  deformities  traction  applied  during 
the  pains  may  of  itself  suffice  to  bring  down  the  head. 
Should  the  obstruction  be  too  great  to  admit  of  this,  it 
is  necessary  to  break  down  and  remove  the  vault  of  the 
cranium.  For  this  purpose  Simpson's  cranioclast 
answers  better  than  any  other  instrument.  One  of  the 
blades  is  passed  within  the  cranium,  the  other,  if  possible,  between  the 
scalp  and  the  skull,  and  the  portion  of  bone  grasped  between  them  is 
broken  off;  this  can  generally  be  accomplished  by  a  twisting  motion  of 
the  wrist  without  using  much  force.  The  separated  portion  of  bone  is 
then  extracted,  the  greatest  care  being  taken  to  guard  the  maternal 
structures  during  its  removal  by  the  fingers  of  the  left  hand.  The 
instrument  is  then  applied  to  a  fresh  part  of  the  skull  and  the  same  pro- 
cess repeated,  until  as  much  of  the  vault  of  the  cranium  as  may  be  neces- 
sary is  broken  up  and  removed. 

Dr.  Braxton  Hicks ^  has  conclusively  shown  that  in  difficult  cases, 
after  the  removal  of  the  cranial  vault,  the  proper  procedure  is  to  bring 
down  the  face,  since  the  smallest  measurement  of  the  skull  after  the 
removal  of  the  upper  part  of  tlie  cranium  is  from  the  orbital  ridge  to 
the  alveolar  edge  of  the  superior  maxillary  bone.  This  alteration  in 
the  presentation  he  proposes  to  effect  by  a  small  blunt  hook  made  for 
the  purpose,  which  is  forced  into  the  orbit,  by  means  of  which  the  face 


Professor  Simpson's 
Basilyst. 


'  Ed'm.  Med.  Joiirn.,  vol.  1879-80,  p.  865. 


Obst.  Trans.,  1867,  vol.  vii.  p.  57. 


516 


OBSTETRIC  OPERATIONS. 


Fjg.  192. 


Fig.  193. 


is  made  to  descend,  liariies  reeonnnond.s  tliut  this  should  he  done  by 
fixing  the  craniotomy  forceps  over  the  forehead  and  face,  and  making 
traction  in  a  backward  direction,  so  Jis  to  get  the  face  j)a.st  tlie  projecting 
promontory  ol"  the  sacrum.  U'he  importance  of  bringing  down  tlie  face 
was  long  ago  j)ointcd  out  by  Burn.s,  but  it  had  b(,-en  lost  sight  of  until 
Hicks  again  drew  attention  to  it  in  the  paper  referred  to.  In  the  class 
of  cases  in  whicii  tliis  procedure  is  vahiable  the  risk  to  the  maternal 
passages  from  the  removal  of  the  fractured  portions  of  bone  must  always 
be  considerable,  and  it  is  of  great  im})ortance  not  only  to  j)re.serve  the 
scalp  as  entire  as  po-ssible,  so  as  to  protect  them,  but  to  use  the  utmost 
po.ssible  care  in  removing  the  broken  pieces  of  bone. 

Extraction  of  the  Body. — When  the  extraction  of  the  head  lias 
been  effected,  either  by  the  cephalotribe  or  the  craniotomy  forceps,  there 
is  seldom  much  difficulty  with  the  body.  By  traction  on  the  head  one 
of  the  axilke  can  easily  be  brought  within  reach,  and  if  the  body  do 
not  readily  pass,  the  blunt  hook  should  be  introduced  and  traction  made 
until  the  shoulder  is  delivered.  The  same  can  then  be  done  with  the 
other  arm.  If  there  be  still  difficulty  the  cephalotribe  may  be  used  to 
crush  the  thorax.  The  body  is,  however,  so  compressible  that  this  is 
rarely  required. 

[The  craniotomy  forceps  chiefly  in  use  with  us 
were  devised  by  the  late  Prof.  Charles  D.  jSIeigs 
for  his  second  operation  upon  i\li-s.  Reybold  of 
Philadelphia  in  1833,  and  have  been  used  re- 
jjeatedly  since,  either  as  tractors  or  for  reducing 
the  size  of  the  foetal  head,  in  cases  of  deformity 
of  the  pelvis.'  Some  obstetricians  prefer  the  less 
curved  and  broader-bladed  instrument  of  Great 
Britain  as  a  tractor  ;  but  for  the  general  ]iurposes 
of  picking  away  the  cranial  bones  aud  drawing 
down  the  base  of  the  skull  in  cases  of  extreme 
pelvic  deformity  there  is  no  more  simple  aj)j)li- 
ance  than  that  of  Dr.  ]Meigs. 

To  act  upon  an  oval  body  like  the  fcetal  head 
Dr.  ]\I.  was  obliged  to  prepare  two  forms  of  fbr- 
cep.s — straight  and  curved — to  ))e  used  as  might 
be  required  according  to  the  part  of  the  skull 
to  be  brokeu  down  or  drawn  upon.  These  are 
lightlv  made,  serrated,  and  12.',  inches  in  length. 
— Ei)".] 

Embryotomy. — There  only  remains  for  us  to 
consider  the  second  cla.ss  of  destructive  operations. 
These  may  be  necessary  in  long-neglected  cases 
of  arm  presentation  in  which  turning  is  found  to  l)e  impracticable.  Here, 
fortunately,  the  question  of  killing  the  fVetus  does  not  arise,  since  it  will, 
almost  necessarily,  have  already  perished  from  the  continuous  pressure. 
We  have  two  operations  to  select  from — decapitation  and  evisceration. 

['  Tlie  illustrations  given  are  taken  from  the  instruments  devised  by  Dr.  Meigs  a.s  an 
improvement  upon  his  original  pattern,  nnd  will  be  seen  to  differ  from  those  usually 
presented  in  American  obstetrical  publications. — Ed.] 


Straight         Curved 

Craniotomy   Craniotomy 

Forceps. "       Forceps. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  THE  FQiTUS.   .017 

The  former  of  these  is  an  operation  of  great  antiquity,  having  l)een 
fully  described  by  Cclsus.  It  consists  in  severing  the  neck,  so  as  to 
separate  the  head  from  the  body  ;  the  ]>ody  is  tiien  withdrawn  by  means 
of  the  protruded  arm,  leaving  the  head  in  vtero,  to  be  snbsc^quently 
dealt  with.  If  the  neck  can  be  reached  without  great  difficulty — and 
in  the  majority  of  cases  the  shoulder  is  sufficiently  pressed  down  into 
the  pelvis  to  render  this  quite  i)0ssible — there  can  be  no  doubt  that  it  is 
much  the  simpler  and  safer  operation. 

The  whole  question  rests  on  the  possibility  of  dividing  the  neck. 
For  this  purpose  many  instruments  have  been  invented.  (The  one 
generally  recommended  in  England  is  known  as  Ramsbotham's  hook, 
and  consists  of  a  sharply  curved  hook  with  an  internal  cutting  edge) 
This  is  guided  over  the  neck,  which  is  divided  by  a  sawing  motion. 
There  is  often  considerable  difficulty  in  placing  the  instrument  over  the 
neck,  although  if  this  were  done  it  would  doubtless  answer  well.  Others 
have  invented  instruments  based  on  the  principle  of  the  apparatus  for 
plugging  the  nostrils,  by  means  of  which  a  spring  is  passed  round  the 
neck,  and  to  the  extremity  of  the  spring  a  short  cord  or  the  chain  of 
an  ecraseur  is  attached ;  the  spring  is  then  withdrawn  and  brings  the 
chain  or  cord  into  position.  The  objection  to  any  of  these  apparatuses 
is  that  they  are  unlikely  to  be  at  hand  when  required,  for  few  practi- 
tioners provide  themselves  with  costly  instruments  which  they  may 
never  require.  It  is  of  importance,  therefore,  that  Ave  should  have  at 
our  command  some  means  of  dividing  the  neck  which  is  available  in 
the  absence  of  any  of  these  contrivances.  ^Dubois  recommends  for  this 
purpose  a  strong  pair  of  blunt  scissors.  The  neck  is  brought  as  low  as 
possible  by  traction  on  the  prolapsed  arm,  and  the  blades  of  the  scissoi-s 
guided  carefully  up  to  it.  By  a  series  of  cautious  snipping  movements 
it  is  then  completely  divided  from  below  upward.  This,  if  the  neck 
be  readily  within  reach,  can  generally  be  effected  without  any  particular 
difficulty,  j  Dr.  Kidd  of  Dublin,^  who  strongly  advocates  this  operation, 
recommends  that  an  ordinary  male  elastic  catheter,  strongly  curved  and 
mounted  on  a  frrm  stilet,  or,  still  better,  on  a  uterine  sound,  should  be 
passed  round  the  neck.  Previous  to  introduction  a  cord  should  be 
passed  through  the  eye  of  the  catheter,  which  is  left  round  the  neck 
when  it  is  withdi-awn.  By  means  of  this  cord  a  strong  piece  of  whip- 
cord or  the  wire  of  an  6craseur  can  easily  be  drawn  round  the  neck  and 
used  for  dividing  it.  The  former,  to  protect  the  maternal  structures, 
mav  be  worked  through  a  speculum,  and  by  a  series  of  lateral  move- 
ments the  neck  is  easily  severed.  The  ecraseur,  however,  offers  special 
advantage,  since  it  entirely  does  away  with  any  risk  of  injuring  the 
mother. 

"Withdrawal  of  the  Body  and  Delivery  of  the  Head. — After  the 
neck  is  divided  the  remainder  of  the  operation  is  easy.  The  body  is 
withdrawn  without  difficulty  by  the  arm,  and  Ave  then  proceed  to  deliA^er 
the  head,  f  By  abdominal  pressure  this  in  most  cases  can  be  jnished 
down  into  the  pelvis,  so  as  to  come  easily  within  reach  of  the  cephalo- 
tribe,  which  is  by  far  the  best  instrument  for  extraction.  '  Preliminary 
perforation  is  not  necessary,  since  the  brain  can  esca])e  through   tlie 

^  Dublin  Quart.  Jouni.  of  Med.  Science,  1871,  vol.  li.  p.  383. 


518  OBSTETRIC  OPERATIONS. 

severed  vertebral  eanal.  The  secret  of  doing  this  easily  is  to  fix  and 
press  down  the  head  sufficiently  Irom  aljove,  otherwise  it  would  slip 
away  from  the  o;i"as]>  of  the  instrument.  The  perforator  and  craniotomy 
ibrceps  may  he  used  if  the  cephalotrihe  be  not  at  hand.  Perforation  is, 
however,  by  no  means  always  easy,  on  account  of  the  nioi)ility  of  the 
head.  After  it  is  accomplished  one  blade  of  the  craniotomy  forceps  is 
pas.sed  within  the  skull,  the  other  externally,  and  the  head  slowly 
drawn  down. 

Evisceration. — The  alternative  operation  of  evisceration  is  a  much 
more  troublesome  and  tedious  procedure,  and  should  only  be  used  when 
the  neck  is  inaccessible.  The  first  step  is  to  j)erforate  the  thorax  at  its 
most  depending  part,  and  to  make  as  wide  an  opening  into  it  as  possi- 
ble in  order  to  gain  access  to  its  contents.  Through  this  the  thoracic 
viscera  are  removed  piecemeal,  being  first  broken  up  as  much  as  possi- 
ble by  the  perforator,  and  then,  the  diaphragm  being  penetrated,  those 
in  the  abdomen.  The  object  is  to  allow  the  body  to  collapse  and  the 
pelvic  extremities  to  descend  as  in  spontaneous  evolution.  This  can  be 
much  facilitated  by  dividing  the  spinal  column  with  a  sti'ong  pair  of 
scissors  introduced  into  the  ojaening  made  in  the  thorax,  so  that  the 
body  may  be  doubled  up  as  on  a  hinge.  Here  the  crotchet  may  find  a 
useful  application,  for  it  can  be  passed  through  the  abdominal  cavity 
and  fixed  on  some  point  in  the  interior  of  the  child's  pelvis,  and  thus 
strong  traction  can  be  made  without  any  risk  of  injury  to  the  mother. 
It  can  be  readily  understood  that  this  process  is  so  lengthy  and  difficult 
as  to  render  it  probably  the  most  trying  of  obstetric  operations;  it  is  cer- 
tainly inferior  in  every  respect  to  decapitation,  and  is  only  to  be  resorted 
to  when  that  is  impracticable. 


I 


CHAPTER    VI. 


THE  CiESAEEAN  SECTION— PORRO'S  OPERATION. 
SYMPHYSIOTOMY. 

History  of  the  Csesarean  Section. — The  Cfcsarean  section  has  per- 
haps given  rise  to  more  discussion  than  any  other  subject  connected 
with  midwifery,  and  there  is  yet  much  difierence  of  opinion  as  to 
the  limits  of,  and  indications  for,  the  operation.  The  period  at  which 
Caesarean  section  was  first  resorted  to  is  not  known  with  accuracy. 
It  seems  to  have  been  practised  by  the  Greeks  after  the  death  of  the 
mother,  and  Pliny  mentions  that  Scipio  Africanus  and  INIanlius  were 
born  in  this  way.  The  name  of  ('a>sar  is  said  to  have  been  given  to 
children  so  extracted,  and  afterward  to  have  been  assumed  as  a  family 
patronymic.     These  children  were  dedicated  to  Apollo,  whence  arose 


THE  CJESABEAN  SECTION.  .519 

the  practice  of  tliin<>;s  sacred  to  that  god  being  taken  under  tlie 
special  protection  of  the  family  of  the  CVesars.  Many  celebrities  have 
been  supposed  to  owe  their  lives  to  the  operation,  among  the  rest 
aEsculapius,  Julius  Qesar,  and  Edward  VI.  of  England.  Regarding  the 
two  latter,  there  is  conclusive  proof  that  the  tradition  is  without  founda- 
tion. There  is  no  doubt  that  the  operation  was  constantly  practised 
on  women  who  had  died  at  an  advanced  period  of  pregnancy,  and 
indeed  it  has  at  various  times  been  enfor(!ed  by  law.  Thus,  among  the 
Romans  it  was  decreed  by  Numa  that  no  pregnant  woman  should  be 
buried  until  the  foetus  had  been  removed  by  abdominal  section.  The 
Italian  laws  also  made  it  necessary,  and  the  operation  has  always  receiv- 
ed the  strong  support  of  the  Roman  Church.  So  lately  as  the  middle 
of  the  eighteenth  century  the  king  of  Sicily  sentenced  to  death  a  phy- 
sician who  had  neglected  to  practise  it.  The  first  authentic  case  in 
"which  the  operation  was  jDcrformed  on  a  living  woman  occurred  in 
1491.  It  was  afterward  practised  by  Nufer  in  159i)  [^]  ;  and  in  1581, 
Rousset  published  a  work  on  the  subject  in  which  a  number  of  success- 
ful cases  were  related.  In  English  works  of  that  time  it  is  not  alluded 
to,  although  it  was  undoubtedly  performed  on  the  Continent,  and  to 
such  an  extent  that  its  abuse  became  almost  proverbial.  We  have 
evidence  in  Shakespeare,  however,  that  the  operation  was  familiarly 
known  in  Great  Britain,  since  he  tells  us  that — P] 

" .  .  .  .  Macduff  was  from  his  mother's  womb 
Untimely  ripped." 

Pare  and  Guillemeau,  amongst  the  writers  of  the  period,  were  noted  for 
their  hostility  to  the  operation,  while  others  equally  strongly  upheld  it. 
In  England  it  has  scarcely  ever  been  performed  in  a  manner  which 
offers  even  the  faintest  hope  of  success.  It  has  been  looked  upon  as 
almost  necessarily  fatal  to  the  mother,  and  it  has  therefore  been  delayed 
until  the  patient  has  arrived  at  the  utmost  stage  of  exhaustion.  For 
example,  in  looking  over  the  record  of  British  cases  it  is  uo  uncommon 
thing  to  find  that  the  Csesarean  section  was  resorted  to  two,  three,  or 
even  six  days  after  labor  had  begun,  and  when  the  patient  was  almost 
moribund.  With  rare  exceptions  within  the  last  few  years  the  opera- 
tion has  been  performed  in  what  may  be  called  a  haphazard  way.  In 
many  cases  long  and  fruitless  attempts  at  delivery  by  craniotomy  had 
already  been  made,  so  that  the  passages  had  been  subjected  to  much 
contusion  and  violence.  Little  or  no  attempt  has  been  made  to  obvi- 
ate the  well-known  risks  of  abdominal  operations ;  no  care  has  been 
taken  to  prevent  blood  and  other  fluids  finding  their  way  into  the 
peritoneal  cavity ;  and  no  means  have  been  adopted  subsequently  to 
remove  them.  It  is,  therefore,  not  so  much  a  matter  of  surprise  that 
the   mortality   has    been   so   great,    but   rather   that   any   cases   have 

[' Probnbly  in  149S ;  the  boy  delivered  lived  to  be  seventy-seven  years  old ;  calcu- 
lating backward  gives  tliis  date.     Rousset  says,  "  about  the  year  1500." — Ed.] 

['■^  Holinshed,  the  historian,  (1577),  makes  Macdufl'  say,  "  I  was  ripped  out."  INIrs. 
Macdufl"  was  probably  operated  on  by  a  cow.  Horned  cattle  have  performed  tlie 
operation  11  times  since  1646,  with  a  loss  of  3  women  and  6  cliildren ;  one  case  in  Edin- 
burgh resulted  favorably  to  both  uiotlier  and  cliild.  Three  male  Macdutls  are  proba- 
bly now  living  in  North  America:  one,  of  twenty-one,  is  at  West  Point. — -Ed.] 


520  OBSTETRIC  OPERATIOXS. 

recovered.  [This  does  not  ap])ly  to  the  nianagcnient  of  several  recent 
operations. — Ed.] 

From  what  Ave  know  of  tli(!  history  of  ovariotomy,  its  early  fatality, 
and  the  extreme  and  even  aj)])arently  exaggerated  preeantions  which  are 
essential  to  its  success,  it  is  iair  to  conclude  that  if  the  (Cesarean  section 
were  performed,  as  it  is  to  be  hoped  it  always  ^\■ill  be  in  future,  with  the 
same  careful  attention  to  minute  details  as  ovariotomy,  the  results  would 
not  be  so  disastrous.  ]\Iaking  every  alloM-auce  for  these  facts,  it  must 
be  admitted  that  tlie  Ciesarean  section,  as  hitherto  performed,  has  been 
necessarilv  almost  a  forlorn  hope,  altliough,  happily,  recent  statistics 
show  that  this  need  no  longer  be  considered  the  case.  In  making  these 
observations  I  have  no  intention  of  contesting  the  McU-established  rule 
of  British  practice  that  it  is  not  admissible  as  an  operation  of  election,  and 
must  onlv  be  resorted  to  when  delivery  per  vias  naturcdes  is  impossible. 

Statistical  Returns  not  Reliable. — The  mortality,  as  given  in  sta- 
tistical returns  from  various  sources,  differs  so  greatly  as  to  make  them 
but  little  reliable.  Radford  has  tabulated  the  operations  performed  in 
Great  Britain  up  to  1879,  [^]  and  the  list  has  been  completed  by  Harris 
up  to  1889.  The  cases  amount  to  154  in  all,  of  Avhich  32  were  success- 
ful. Michaelis  and  Kayser  found  that  out  of  258  cases  and  338  opera- 
1?ions,  54  and  64  per  cent.,  respectively,  were  fatal.  These  iuclude 
operations  performed  under  all  sorts  of  conditions,  even  when  the 
patient  was  almost  moribund ;  and  until  we  are  in  possession  of  a 
sufBcient  number  of  cases  performed  under  conditions  showing  that 
the  result  is  certainly  due  to  the  operation — in  Avhich  it  was  under- 
taken at  an  early  period  of  labor  and  performed  with  a  reasonable 
amount  of  care — it  is  obviously  impossible  to  arrive  at  any  reliable 
conclusions  as  to  the  mortality  of  the  operation.  [The  Csesarean  sta- 
tistics of  the  past,  with  the  exception  of  those  of  the  years  1885,  1886, 
1887,  and  1888,  are  of  very  little  real  value  in  calculating  the  present 
dangers  of  the  Porro-Csesarean  and  Siinger-Csesarean  methods,  which 
have  only  within  the  years  named  ceased  to  be  in  some  degree  experi- 
mental. Old  records  are  of  historical  interest  and  show  the  progressive 
steps  by  which  the  present  low  rate  of  death  was  reached.  Even  the 
miscalled  "  classic "  operation  can  now  be  performed  "with  nnich  less 
risk ;  but  no  wise  man  will  trust  the  uterine  wound  to  nature's  closing 
when  multi])le  suturing  is  so  much  more  to  be  relied  on.  AVhat  is  still 
to  be  learned,  particularly  in  the  United  States  and  Great  Britain,  is  the 
great  value  of  elective,  early,  and  time-chosen  operations. — Ed.]  That 
it  is  necessarily  hopeless  is  certainly  not  the  case,  and  mc  know  that  on 
the  Continent,  where  it  is  resorted  to  much  oftener  and  earlier  in  labor 
than  in  Great  Britain,  there  are  authentic  cases  in  which  it  has  been 
performed  twice,  thrice,  and  even,  in  one  instance,  four  times,  on  the 
same  patient.  Keyser  thinks  that  a  second  operation  on  the  same 
patient  affords  a  l)etter  prognosis  than  a  first,  ]M'()l)ably  because  ])eri- 
toneal  adhesions  resulting  from  the  first  operation  have  shut  off  the 
general  abdominal  cavity  from  the  uterine  wound ;  and  he  believes 
that  in  second  operations  the  mortality  is  not  more  than  29  j)er  cent. 

['  Obscrvniiom  on  the  CcBsarean  Section  and  Craniotomy,  by  Thomas  Radford,  M.  D., 
London,  1880.— Ed.] 


THE  CESAREAN  SECTION.  521 

The  Caesarean  Section  in  America. — The  Caesarean  section  has 
been  much  more  successful  in  America  than  in  Great  Britain.  Dr. 
Harris  of  Phihidclpliia,  who  has  paid  much  attention  to  the  subject, 
lias  collected  184  cases  occurring  in  the  United  States,  of  which  70,  or 
about  38  per  cent.,  we're  successful  as  regards  the  mother.  These 
[relatively]  favorable  results  he  refers  partly  to  the  fact  that  none  of 
the  American  cases  were  the  subjects  of  mollities  ossium,  rachitic 
patients  forming  one-half  of  the  entire  number,  partly  to  the  preva- 
lence of  habits  of  beer  and  gin-drinking  in  Great  Britain.  He  also 
gives  some  interesting  facts  showing  how  remarkably  the  mortality  of 
the  operation  is  lessened  when  it  is  performed  soon  and  the  patient  is 
not  exhausted  by  long  and  fruitless  labor.  (  Out  of  28  selected  cases 
of  this  kind,  21,  or  2.5  per  cent.,  were  successful.  I  [23  children  were 
delivered  alive,  and  19  were  saved. — Ed.]  The  latest  European  sta- 
tistics show  that  the  modifications  of  the  operation  now  universally 
adopted  upon  the  continent  of  Europe  are  followed  by  the  most  grati- 
fying results.  Thus,  out  of  22  recent  operations  18  mothers  recovered. 
Results  to  the  Child. — The  mortality  of  the  children  likewise  can- 
not be  ascertained  from  statistical  returns,  since  in  the  large  majority  of 
cases  in  which  dead  children  were  extracted  the  result  had  nothing  to 
do  with  the  operation.  Indeed,  there  is  nothing  in  the  operation  itself 
which  can  reasonably  be  supposed  to  aifeet  the  child.  /If,  therefore,  the 
child  be  alive  when  the  operation  is  commenced,  there  is  every  proba- 
bility of  its  being  extracted  alive  ;|  and  Radford's  conclusion,  that  "  the 
risk  to  infants  in  Caesarean  births  is  not  much  greater  than  that  which 
is  contingent  on  natural  labor,  provided  correct  principles  of  practice 
are  adopted,"  probably  very  nearly  represents  the  truth.  [The  records 
of  elective  operations  show  a  mere  fraction  of  foetal  deaths. — Ed.] 

Causes  Requiring"  the  Operation. — TheCsesarean  section  is  required 
^vhen  there  is  such  defective  proportion  between  the  child  and  the  mater- 
nal passages  that  even  a  mutilated  foetus  cannot  be  extracted.  This  in 
by  far  the  greatest  number  of  cases  is  due  to  deformity  of  the  pelvis 
arising  from  rickets  or  mollities  ossium.  The  latter  may  occur  in  a 
patient  who  has  been  previously  healthy  and  who  has  given  birth  to 
living  children.  It  is  a  more  common  cause  of  the  extreme  varieties 
of  deformity  than  rickets ;  and  out  of  132  British  cases  tabulated  by 
Radford,  P]  in  56  tlie  deformity  was  produced  by  osteomalacia  and  in 
31  by  rickets.  In  certain  cases  the  pelvis  itself  may  be  of  normal  size, 
but  has  its  cavity  obstructed  by  a  solid  tumor  of  the  ovary,  of  the  uterus 
itself,  or  one  growing  from  the  pelvic  wall.  The  obstruction  may  also 
depend  on  morbid  conditions  of  the  maternal  soft  parts,  of  which  the 
most  common  is  advanced  malignant  disease  of  the  cervix.  Other  con- 
ditions may,  however,  render  the  operation  essential.  Thus,  Dr.  New- 
man ^  records  a  case  in  which  he  performed  it  for  insurmountable  resist- 
ance and  obstruction  of  the  cervix  which  M'as  believed  at  that  time  to 
be  caused  by  malignant  disease.  The  patient  recovered,  and  was  subse- 
quently delivered  naturally  and  without  anything  abnormal  being  made 
out.  This  renders  it  probable  that  the  disease  was  not  malignant,  and 
it  may  possibly  have  been  an  extensive  inflammatory  exudation  into  the 

[1  Edition  of  1880.— Ed.]  ^  Obst.  Trans.,  1866,  vol.  vii.  p.  343. 


522  OBSTETRIC  OPERATIOyS. 

tissues  of  the  cervix  sul)Sf([nenl]y  :il)S(»rl)e(l.  I  myself  was  ])resent  at  a 
( 'lesarean  section  pcrfornud  in  ("alcutta  in  the  year  1857,  when  the  pelvis 
was  so  imifornily  blocked  u})  with  exudation,  j))-oijal)ly  due  to  extensive 
pelvic  celhditis  or  lueinatocele,  that  the  operation  w.is  essential. 

Limits  of  Obstruction  Justifying  the  Operation. — Different 
accoucheurs  have  iixed  on  various  limits  for  the  operation.  Most 
British  authorities  are  of  opinion  that  it  need  not  be  resorted  to  if  the 
smallest  diameter  of  the  ])elvis  exceed  1 -J  inches.'  This  (juestion  has 
already  been  considered  in  discussing  cranTotoni}',  and  it  has  been  shown 
that  a  mutilated  foetus  may  be  drawn  through  a  pelvis  of  li  inches 
antero-posterior  diameter,  provided  there  be  a  space  of  3  inches  in  the 
transverse  diameter.  If  sufficient  space  for  using  the  necessary  instru- 
ments do  not  exist,  the  Csesareau  section  may  be  required,  even  when 
there  is  a  larger  antero-posterior  diameter  than  1^-  inches.  This  is 
especially  likely  to  occur  when  we  have  to  do  with  deformity  arising 
from  mollities  ossium,  in  "which  the  obstruction  is  in  the  sides  and  out- 
let of  the  pelvis,  the  true  conjugate  being  sometimes  even  elongated. 
On  the  Continent  the  Caesarean  section  is  constantly  practised  as  an  ope- 
ration of  election  when  the  smallest  diameter  measures  from  2  to  2^ 
inches ;  and  when  the  child  is  known  to  be  alive  some  foreign  authors 
recommend  it  when  there  is  as  much  as  3  inches  in  the  antero-posterior 
diameter.  In  Great  Britain,  where  the  life  of  the  child  is  most  prop- 
erly considered  of  secondary  importance  to  the  safety  of  the  mother,  we 
cannot  fix  one  limit  for  the  operation  when  the  child  is  living  and 
another  when  it  is  dead.  Nor,  I  think,  can  we  admit  the  desire  of  the 
mother  to  run  the  risk,  rather  than  sacrifice  the  child,  as  a  justification 
of  the  operation,  although  this  is  laid  down  as  an  indication  by  Schroe- 
der.^  Great  as  are  the  dangers  attending  craniotomy  in  extreme  deform- 
ity, there  can  be  no  doubt  that  we  must  perform  it  whenever  it  is  prac- 
ticable, and  only  resort  to  the  Csesarean  section  when  no  other  means 
of  delivery  are  possible. 

[One  of  the  vital  questions  of  the  day  is,  "  Shall  the  Ctesarean  ope- 
ration be  performed  in  cases  under  relative  indications  f"  That  is,  Is  it 
proper  to  elect  to  perform  the  operation  where  the  indications  for  it  are 
not  absolute  and  positive?  If  by  foetal  destruction  the  mother  can  in 
all  probability  be  saved,  is  it  a  justifiable  act  to  run  a  greater  risk  in 
order  to  save  the  child?  Are  the  wishes  of  the  parents  for  a  living 
child  to  be  considered  in  deciding  as  to  the  method  of  delivery?  In 
view  of  the  fact  that  a  premature  delivery  cannot  save  the  child  in  a 
given  case,  and  the  mother  has  already  lost  one  or  more  fwtuses  by  cra- 
niotomy, is  it  proper  to  save  the  child  by  an  operation  in  which  one  out 
of  five  or  six  women  have  died?  We  think  it  is,  and  for  the  reason 
that  such  cases  generally  have  a  less  mortality  than  the  average  here 
given. — Ei).] 

For  this  reason  I  think  it  unnecessary  to  discuss  the  question  whether 
w^e  are  justified  in  destroying  the  foetus  in  several  successive  pregnan- 
cies when  the  mother  knows  that  it  is  impossible  for  her  to  give  birth 

'  In  Dr.  Parry's  table  of  70  craniotomies  there  are  34  cases  of  2  to  2^  inches  con- 
jugate. 
^  Manual  of  Midwifery,  p.  202. 


THE  CESAREAN  SECTION.  523 

to  a  living  child.  Denman  was  the  first  to  question  the  advisal)ility  of 
repeating  craniotomy  on  the  same  patient.  Amongst  modern  authors 
Radlbrd  takes  the  most  decided  view  on  this  point,  and  distinctly  teaches 
that  even  when  delivery  by  craniotomy  is  possible  it  "can  be  justified 
on  no  principle,  and  is  only  sanctioned  by  the  dogma  of"  the  schools  or 
by  usage,"  and  that  therefore  the  Csesarean  section  should  be  performed 
with  the  view  of  saving  the  child.  Doubtless  much  can  be  said  from 
this  point  of  view ;  but  nevertheless  he  would  be  a  bold  man  who  would 
deliberately  elect  to  perform  the  Csesarean  section  on  such  grounds.^  It 
is  to  be  hoped,  however,  that  in  these  days  the  induction  of  premature 
labor  or  abortion  would  always  spare  us  the  necessity  of  deciding  so 
delicate  a  point. 

Post-mortem  Csesarean  Operation. — The  Csesarean  section  may 
also  be  required  in  cases  in  which  death  has  occurred  during  pregnancy 
or  labor.  This  was  the  indication  for  which  it  was  fii'st  employed,  and 
it  has  constantly  been  performed  when  a  pregnant  woman  has  died  at 
an  advanced  period  of  utero-gestation.  There  is  no  doubt  that  a  prompt 
extraction  of  the  child  under  these  circumstances  has  frequently  been  the 
means  of  saving  its  life,  but  by  no  means  so  often  as  is  genei:ally  sup- 
posed. Thus,  Schwarz  ^  showed  that  out  of  107  cases  not  one  living 
child  was  extracted.  Duer^  has  written  an  interesting  paper  on  this 
subject,  in  which  he  has  tabulated  55  cases  of  post-mortem  Csesarean 
sections.  In  40  a  living  child  was  extracted,  the  time  elapsing  after 
the  death  of  the  mother  being  as  follows :  "  Between  one  and  five 
minutes,  including  '  immediately '  and  '  in  a  few  minutes,'  there  were  21 
cases ;  between  five  and  ten  minutes,  none  ;  between  ten  and  fifteen 
minutes,  13  cases;  between  fifteen  and  twenty-three  minutes,  2  cases; 
after  one  hour,  2  cases ;  and  after  two  hours,  2  cases."  In  thosej 
extracted,  however,  after  the  lapse  of  an  hour  the  children  did  not  ulti-j 
mately  survive,  and  the  cases  themselves  seem  open  to  some  doubt. 

Want  of  Success  in  Post-mortem  Operation. — The  reason  that 
the  want  of  success  has  been  so  great  is  doubtless  the  delay  that  must 
necessarily  occur  before  the  operation  is  resorted  to,  for,  independently 
of  the  fact  that  the  practitioner  is  seldom  at  hand  at  the  moment  of 
death,  the  very  time  necessary  to  assure  ourselves  that  life  is  actually 
extinct  will  generally  be  sufficient  to  cause  the  death  of  the  foetus. 
Considering  the  intimate  relations  between  the  mother  and  child,,  we 
can  scarcely  expect  vitality  to  remain  in  the  latter  more  than  a  quarter, 
or,  at  the  outside,  half,  an  hour  after  it  has  ceased  in  the  former.  The 
recorded  instances  in  which  a  living  child  was  extracted  ten,  twelve,  and: 
even  forty  hours  after  death  were  most  probably  eases  in  which  thei 
mother  fell  into  a  prolonged  trance  or  swoon,  during  the  continuance  of/ 
which  the  child  must  have  been  removed.     A  few  authentic  cases,  how-^ 

^  This  was  done  twice  siiccessfnllv  by  Prof.  William  Gibson  in  the  case  of  Mrs.  Eey- 
bold  of  Philadelphia  in  1835  and  1837,  after  she  had  twice  been  delivered  by  craniot- 
omy under  Prof.  Charles  D.  Meigs,  who  declined  destroying  any  more  children  for 
her.  Mrs.  R.  still  lives  at  the  age  of  seventy,  and  the  daughter  and  son  likewise,  with 
their  six  children. — Harris'  note  to  3d  American  edition.  [She  died  Aug.  15,  1885, 
aged  76. — Ed.] 

2  Monat.  f.  Geburt.  suppl.  1862,  Bd.  xviii.  S.  112.  ^ 

3  "  Post-mortem  Delivery,"  Amer.  Journ.  of  Obst.,  1879,  vol.  xii.  pp.  1  and  374. 


524  OBSTETRIC  OPERATIONS. 

ever,  are  known  in  which  there  can  be  no  reasonable  doubt  that  the 
operation  was  performed  successfully  several  hours  after  the  mother  was 
actually  dead. 

I  Since,  then,  there  is  a  chance,  however  slight,  of  saving  the  child's 
life,  we  are  bound  to  perform  the  operation,  even  when  so  much  time 
has  elapsed  as  to  render  the  chances  of  success  extremely  small.)  It 
might  be  considered  almost  superfluous  to  insist  on  the  uece&sity  of 
assuring;  ourselves  of  the  mother's  death  before  commencing  the  neces- 
sary  incisions;  but,  unfortunately,  numerous  instances  are  known  in 
which  mistakes  in  diagnosis  have  been  made,  and  in  which  the  tirst 
steps  of  the  operation  have  shown  that  tiie  mother  was  still  alive.  The 
operation  should  therefore  always  be  performed  with  the  same  care  and 
caution  as  if  the  mother  were  living.  If  death  have  occurred  during 
labor,  some  have  advised  version  as  a  preferable  alternative.  This  can 
only  be  resorted  to  with  any  hope  of  success  if  the  passages  be  in  a  con- 
dition to  admit  of  delivery  with  rapidity ;  otherwise  the  delay  occa- 
sioned by  dilatation,  even  when  forcibly  accom})lished,  and  the  drawing 
of  the  child  through  the  pelvis,  will  be  almost  necessarily  fatal.  The 
only  argument  in  favor  of  version  is  that  it  is  less  painful  to  the  friends; 
and  if  they  manifest  a  decided  objection  to  the  Cesarean  section,  there 
can  be  no  reason  why  an  attempt  to  save  the  child  in  this  way  should 
not  be  made. 

Causes  of  Death  after  Caesarean  Section. — The  causes  of  death 
after  the  Ceesarean  section  may,  speaking  generally,  be  classed  under 
four  principal  heads:  hemorrhage,  perit(mitis  and  metritis,  shock,  septi- 
ceemia  and  exhaustion  from  long  delay.  These  are  pretty  much  the 
same  as  those  following  ovariotomy,  and  the  resemblance  between  the 
two  operations  is  so  great  that  modern  experience  as  to  the  best  mode 
of  performing  ovariotomy,  as  well  as  regards  the  after-treatment,  may 
be  taken  as  a  guide  in  the  management  of  cases  of  Caesarean  section. 

Hemorrhage  to  an  alarming  extent  is  a  frequent  complication,  though 
seldom  the  cause  of  death.  Thus,  out  of  88  operations,  the  particulars 
of  which  have  been  carefully  noted,  severe  hemorrhage  occurred  in  14, 
6  of  which  terminated  successfully,  and  in  4  only  could  the  fatal  result 
be  ascribed  to  the  loss  of  blood.  In  1  of  these  the  source  of  the  hem- 
orrhage is  not  mentioned,  in  another  it  came  from  the  wound  in  the 
abdominal  wall, and  in  the  other  2  from  the  uterine  incision  being  made 
directly  over  the  placenta.  In  neither  of  the  two  latter  was  the  loss  of 
blood  immediatelv  fatal,  for  it  was  checked  bv  uterine  contraction,  and 
only  recurred  after  many  hours  had  elapsed.  The  divided  uterine 
sinuses,  and  the  open  mouths  of  the  vessels  at  the  placental  site  are  the 
most  common  sources  of  hemorrhage. 

Much  may  be  done  to  diminish  the  risk  of  bleeding,  but  even  with 
every  precaution  it  must  be  a  source  of  danger.  Hemorrhage  from  the 
abdominal  wall  may  be  best  prevented  by  making  (the  incision  as  nearly 
as  possible  in  the  line  of  the  linea  alba;  so  as  not  lo  Mound  the  epigas- 
tric arteries,  and  by  controlling  bleeding  by  pressure-forccjis  as  we  pro- 
ceed, as  is  done  in  ovariotomy.  The  principal  Toss  oF  blood  will  be  met 
with  in  dividing  the  uterus,  and  this  will  be  the  greatest  when  the  incis- 
ion is  near  or  over  the  placental  site,  where  the  largest  vessels  are  met 


THE  CMSAREAN  SECTION.  525 

with.  We  are  recominended  to  ascertain  the  position  of  the  placenta 
by  auscultation,  and  thus,  if  possible,  to  avoid  openino;  the  uterus  near 
its  insertion.  But  even  if  we  admit  the  placental  souffle  to  be  a  guide 
to  its  situation  if  the  placenta  be  attached  to  the  anterior  walls  of  the 
uterus,  a  knowledge  of  its  position  would  not  always  enable  us  to  avoid 
opening  the  uterus  in  its  immediate  vicinity.  (We  must,  in  the  event 
of  its  lying  under  the  incision,  rather  hope  to  control  the  hemorrhage 
by  removing  it  at  once  fi'om  its  attachments  and  rapidly  emjptying  the 
uterus.  I  AVhen  the  child  has  been  removed  there  may  be  a  large  escape 
of  blood,  but  this  will  generally  be  stopped  by  the  contraction  of  the 
uterus  in  the  same  manner  as  after  natural  labor.  Should  contraction 
not  take  place,  the  uterus  may  be  firmly  grasped  for  the  purpose  of 
exciting  it.  This  plan  is  advocated  by  Ludwig  Winckel,  who  had  a 
large  experience  in  the  operation,  and  by  using  free  compression  in  this 
way,  and  making  a  point  of  not  closing  the  wound  until  the  uterus  is 
firmly  contracted,  he  has  never  met  with  any  inconvenience  from  hem- 
orrhage. If  bleeding  continue,  styptic  applications  may  be  used,  as  in 
a  case  reported  by  Hicks,  who  was  obliged  to  swab  out  the  uterine  cav-. 
ity  with  a  solution  of  perchloride  of  iron.  The  method  first  used  by  [^]  ) 
Miiller,  and  now  adopted  by  most  operators,  of  placing  a  soft-rubber  f 
cord  round  the  uterus  after  its  contents  have  been  removed,  will  tend 
effectually  to  control  hemorrhage,  and  should  always  be  employed.  [It 
is  often  applied  before  the  uterine  incision  is  made. — Ed.] 

Among  the  most  frequent  causes  of  death  are  peritonitis  and  metritis. 
Kayser  attributes  the  fatal  results  to  them  in  77  out  123  unsuccessful 
cases.  [Of  79  deaths  specially  noted  in  this  country,  31  were  from 
peritonitis,  17  frona  exhaustion,  14  from  septicaemia,  12  from  shock, 
and  5  from  internal  hemorrhage. — Ed.] 

The  mere  division  of  the  peritoneum  will  not  account  for  the  fre- 
quency of  this  complication,  since  its  occurrence  is  considerably  more 
frequent  than  after  ovariotomy,  in  which  the  injury  to  the  peritoneum 
is  quite  as  great,  and  indeed  greater  if  we  take  into  account  the  adhe- 
sions which  have  to  be  divided  or  torn  in  that  operation. 

The  division  of  the  uterus  must  be  regarded  as  one  source  of  this 
danger.  Dr.  West  lays  great  stress  on  its  unfavorable  condition  after 
delivery  for  reparative  action.  He  believes  that  the  process  of  involu- 
tion or  fatty  degeneration  which  commences  in  the  muscular  fibres  pre- 
vious to  delivery  renders  them  peculiarly  unfitted  to  cicatrize ;  and  he 
points  out  that  on  post-mortem  examination  the  edges  of  the  incision 
have  been  found  dry,  of  unhealthy  color,  gaping,  and  showing  no  tend- 
ency to  heal.  On  this  account  Hicks  and  others  have  operated  ten  days 
or  more  before  the  full  period  of  labor,  in  the  hope  that  the  risk  from 
this  source  might  be  avoided.  [Recent  careful  investigations  have  proved 
this  to  be  a  fallacy.  There  is  nothing  in  the  post-partum  uterine 
changes  to  interfere  with  the  process  of  healing  if  the  tissues  of  the 
organ  are  in  a  normal  state.  An  operation  before  labor  or  just  after  it 
has  begun  will  be  followed  usually  by  a  rapid  cicatrization  if  thcAvoman 
is  in  fair  health. — Ed.]  It  is  by  no  means  certain,  however,  that  the 
change  in  the  uterine  fibres  is  tlie  cause  of  the  wound  not  healing,  and 

\}  It  was  by  Prof.  Litzmann  of  Kiel,  in  1878. — Ed.] 


526  OBSTETRIC  OPERATIONS. 

involution  will  commence  at  once  when  the  uterus  is  emptied,  even  if 
the  full  period  of  pregnancy  have  not  arrived.  As  a  point  of  ethics, 
moreover,  it  is  questionable  if  we  are  justified  in  anticipating  the  date 
of  so  dangerous  an  operation,  even  by  a  few  weeks,  unless  the  l^enefit  to 
be  derived  is  very  decided  indeed.  [The  teaching  of  Profs.  Goodell, 
(Lusk,  and  Kelly,  all  successful  operators,  having  saved  seven  cases  collec- 
jtively,  is  not  in  correspondence  Avitli  this  opinion.  Having  far  less  fear 
/of  the  operation  than  Prof.  Playfair  has,  our  best  operators  prefer  in 
(many  cases  to  make  the  section  before  Jabor  has  commenced,  so  as  to 
select  an  opportune  time  and  secure  the  best  possible  results. — Ed.] 

One  important  cause  of  peritonitis  is  the  escape  of  the  lochia  through 
the  uterine  incision  into  the  cavity  of  the  peritoneum,  Mhieh  there 
decompose  and  act  as  an  unfailing  source  of  irritation.)  This  maybe 
prevented,  to  a  great  extent,  by  seeing  that  the  os  uten  is  patulous,  so 
as  to  afford  a  channel  for  the  escape  of  discharges  and  by  effective 
closing  of  the  uterine  wound  by  sutures.  In  addition,  there  is  the 
danger  arising  from  blood  and  liquor  amnii  escaping  into  the  peritoneum, 
and  subsequently  decomposing.  There  is  little  evidence  that  ^'  la  toilette 
du  peritoiue,"  on  which  ovariotomists  now  lay  so  much  stress,  has  ever 
been  particularly  attended  to  in  Csesarean  operations.  [^] 

The  chief  predisj)osing  cause  of  these  inflammations,  however,  must 
be  looked  for  in  the  condition  of  the  patient,  just  as  asthenic  inflamma- 
tion in  ovariotomy  is  most  frequently  met  with  in  those  whose  general 
health  is  broken  down  by  the  long  continuance  of  the  disease.  We  are 
fully  justified,  therefore,  in  assuming  that  peritonitis  and  metritis  will 
be  more  likely  to  occur  after  the  Csesarean  section  when  that  operation 
has  been  unnecessarily  delayed  and  when  the  patient  is  exhausted  by  a 
protracted  labor.  In  proof  of  this  we  find  that  in  a  large  proportion 
of  the  cases  above  mentioned  peritonitis  occurred  when  the  operation 
was  performed  under  unfavorable  conditions. 

The  sources  of  septicsemia  are  abundantly  evident,  not  the  least, 
probably,  being  absorption  by  the  open  vessels  in  the  uterine  incision. 

The  last  great  danger  is  general  shock  to  the  nervous  system.  In 
Kayser's  123  cases,  30  of  the  deaths  are  referred  to  this  cause.  In  the 
large  majority  of  these  the  patient  was  profoundly  exhausted  before 
the  operation  was  begun.  It  is  in  predisposing  to  these  nervous  com- 
plications that  "we  should,  a  priori,  expect  that  vacillation  and  delay 
w^ould  be  most  hurtful ;  and  in  operating  Avheu  the  patient's  strength  is 
still  unimpaired  w^e  afford  her  the  best  chance  of  bearing  the  inevitable 
shock  of  an  operation  of  such  magnitude. 

In  addition,  a  few  cases  have  been  lost  from  accidental  complications, 
w'hich  are  liable  to  occur  after  any  serious  operation,  and  which  do  not 
necessarily  depend  on  the  nature  of  the  procedure. 

There  is  only  one  source  of  daiiger  special  to  the  child  which  is 
worthy  of  attention.  fAs  the  infant  is  W'uv^  rciiiovcd  from  the  cavity 
of  the  uterus  the  muscular  parietes  sometimes  contract  with  great  rapidity 
and  force,  so  as  to  seize  and  retain  some  part  of  its  body. )  This  occurred 
in  two  of  Dr.  Radford's  cases,  and  in  one  of  them  it  is  stated  that  "  the 

\}  This  certainly  does  not  apply  to  many  recent  operations  in  our  country  and  upon 
the  continent  of  Europe. — Ed.] 


THE  CESAREAN  SECTION.  627 

child  was  vigorously  alive  when  first  taken  hold  of,  but  from  the  length  of 
time  occupied  in  extracting  the  head  it  became  so  enfeebled  as  to  show 
only  slight  signs  of  life/'  and  subsequently  all  attempts  at  resuscitation 
failed.  I  have  myself  seen  the  head  caught  in  this  way,  and  so  forcibly 
retained  that  a  second  incision  was  required  to  release  it.  In  Dr.  Rad- 
ford's cases  the  placenta  happened  to  be  immediately  under  the  incision, 
and  he  attributes  the  inordinate  and  rapid  contraction  of  the  uterus  to 
its  premature  separation.  It  is  difficult  to  believe  that  this  was  more 
than  a  coincidence,  because  the  contraction  does  not  take  place  until  the 
greater  part  of  the  child's  body  has  been  withdrawn,  and  because  numer- 
ous cases  are  recorded  in  which  the  uterus  was  opened  directly  over  the 
placenta  or  in  which  it  was  lying  loose  and  detached,  in  none  of  which 
this  accident  occurred.  The  true  explanation  may,  I  think,  be  found 
in  the  varying  irritability  of  the  uterus  in  different  cases. 

Irrespective  of  the  risk  of  portions  of  the  child  being  caught  and 
detained,  rapid  contraction  is  a  distinct  advantage,  since  the  danger  of 
hemorrhage  is  thereby  thus  diminished.;'  Serious  consequences  may  be 
best  avoided  by  removing,  when  practicable,  the  head  and  shoulders  of 
the  child  first,  or  by  employing  both  hands  in  extraction,  one  being 
placed  near  the  head,  the  other  seizing  the  feet.)  Either  of  these 
methods  is  preferable  to  the  common  practice  of  laying  hold  of  the 
part  that  may  chance  to  lie  most  conveniently  near  the  line  of  incision. 
If  this  point  were  properly  attended  to,  although  the  detention  of  the 
lower  extremities  might  occasionally  occur,  the  life  of  the  child  would 
not  be  imperilled.  [We  teach  just  the  reverse  in  this  country,  and 
timt  is  to  deliver  by  the  feet ;  which  is  also  in  accordance  with  the 
directions  given  in  continental  Europe.  A  rapid  pedal  delivery  runs 
no  risk  of  the  foetus  being  caught  by  the  neck. — Ed.] 

The  Patient  should  be  Prepared  for  the  Operation. — The  prep- 
aration of  the  patient  for  the  operation  should  seriously  occupy  the 
attention  of  the  practitioner,  and  this  is  the  more  essential  since  almost 
all  patients  requiring  the  Csesarean  section  are  in  a  wretchedly  debili- 
tated condition.  If  the  patient  be  not  seen  until  she  is  actually  in 
labor,  of  course  this  is  out  of  the  question.  But  this  will  rarely  be  the 
case,  since  the  deformed  condition  of  the  patient  must  generally  have 
attracted  attention.  Every  possible  means  should  be  taken,  therefore, 
when  practicable,  to  improve  the  general  health  by  abundance  of  simple 
and  nourishing  djet,  plenty  of"  fresh  air,  and  suitable  tonics  (amongst 
which  preparations  of  iron  should  occupy  a  prominent  place),  while  the 
state  of  the  secretions,  the  bowels,  skin,  and  kidneys  should  be  specially 
attended  to.  Whenever  it  is  possible  a  large,  airy  apartment  should  be 
selected  for  the  operation,  which  should  never  be  done  in  a  hospital  if 
other  arrangements  be  practicable.  [^]  These  details  may  seem  trivial  and 
unnecessary,  but  to  ensure  success  in  so  hazardous  an  undertaking  no 
care  can  be  considered  superfluous,  and  probably  the  want  of  attention 
to  such  points  has  had  much  to  do  with  increasing  the  mortality. 

The  question  arises  whether  we  should  operate  before  labor  has  com- 
menced.   By  selecting  our  own  time,  as  some  have  advised,  we  certainly 

\}  In  this  country  we  believe  now  that  cases  do  better  in  hospital,  as  a  general  rule, 
than  at  tlieir  own  homes. — Ed.] 


628  OBSTETRIC  OPERATIONS. 

have  llic  advaiitairc  <»i'  ojx'ratinjx  iiiuk'i-  the  most   favoral)lo  oonditioiis 

i instead  of  possil)lv  liui-ricdly.    (Tlicre  arc,  liowcvcr,  miiiHTous  advan- 
tages in  waiting  until  s])ontaneous  uterine  aetion  has  ooniinenced  which 
seem  to  me  to  more  than  counterbalance  the  advantages  of  choosing  our 
own  time.)    Prominent  among  these  is  the  })artial  opening  of  the  os 
uteri,  so  as  to  aflbrd  a  channel  ibr  the  escape  of  the  lochia,  and  the  cer- 
taintv  of  active  contraction  of  the  uterus  to  arrest  hemorrhage.     Barnes 
recommends  that  premature  labor  should  be  first  induced,  and  then  the 
operation  performed.    This  seems  to  me  to  introduce  a  needless  element 
of  com})lexity  ;  and  besides,  in  cases  of  great  deformity  it  is  by  no 
means  always  easy  to  reach  the  cervix  with  the  view  of  bringing  on 
labor.     All  needful  arrangements  should  be  made,  so  as  to  avoid  hurry 
and  excitement  when  the  operation  is  commenced,  and  we  may  then 
wait  patiently  until   labor  has   fiiirly  set  in./  [I  have  seen  ojicrations 
yjperformed  before  labor  began,  soon  after  laoor  was  induced,  and  after 
'/it  came  on  naturally,  and  confess  that  I  prefer  the  advantages  aff()rded 
/jbv  the  first.     Unless  there  is  stenosis  of  the  cervix  it  Avill  generally  be 
}}  wide  enough  open  for  drainage ;  if  it  is  not,  labor  can  be  safely  induced 
1 1  at  a  selected  time. — Ed.] 

The  Administration  of  Anaesthetics. — The  operation  itself  is  sim- 
ple. The  patient  should  be  placed  on  a  table  in  a  good  light  and  with 
the  temperature  of  the  room  raised  to  about  65°.  Chloroform  has  so 
frequently  been  followed  by  severe  vomiting  that  it  is  probably  better 
not  to  administer  it.  For  the  same  reason,  Mr.  Spencer  Wells  has  long 
given  up  using  it  in  ovariotomy,  and  finds  that  chloro-methyl  answers 
admirably;  ether  also  is  devoid  of  the  disadvantages  of  chloroform.  In 
one  or  two  cases  local  anaesthesia  has  been  used  by  means  of  two  sjiray- 
producers  acting  suiiiirtaneously ;  and  this  plan,  if  the  patient  have  suf- 
ficient fortitude  to  dispense  with  general  anaesthesia,  has  the  further 
advantage  of  stimulating  the  uterus  to  poMcrful  contraction. 

To  ensure  as  great  a  measure  of  success  as  possible  the  operation 
should  be  performed  with  all  the  minute  precautious  used  in  ovari- 
otomy. 

Description  of  the  Operation. — The  incision  should  be  made  as 
much  as  possible  in  the  line  of  the  Ijiiea^alba,  so  as  to  avoid  wounding 
the  epigastric  arteries.  On  account  of  the  deformity  the  configuration 
of  the  abdomen  is  often  much  altered,  and  some  liave  advised  that  the 
incision  should  be  made  oblique  or  transverse  and  on  the  most  promi- 
nent part  of  the  abdomen.  The  risk  of  hemorrhage  being  thus  much 
increased,  the  practice  is  not  to  be  recommended.  [The  color-lhie  .so 
common  in  ])rcgnancy  will  indicate  in  many  women  the  direction  the 
incision  is  to  take  in  order  to  strike  the  linea  alba  correctly.  The  more 
truly  this  is  done,  the  less  likely  is  hemorrhage  to  occur  from  the  edges 
of  the  wound. — Ed.]  (The  incision,  commencing  a  little  above  the 
umbilicus,  is  carried  down  for  about  three  inches  below  it.  )  The  skin 
and  muscular  fibres  are  carefully  divided,  layer  by  layer,  until  the  shin- 
ing surface  of  the  peritoneum  is  reached,  and  any  bleeding  vessels 
should  be  secured  as  we  proceed.  A  small  oj)eniug  is  now  made  in  the 
pei'itoneum,  which  should  be  laid  open  along  the  whole  length  of  the 
incision  upon  two  fingers  of  the  left  hand  introduced  as  a  guide.     A 


THE  CJESAREAN  SECTION.  529 

few  silk  sutures,  three  or  four,  should  now  he  passed  throufrh  the  upper 
end  of  the  ineision.  The  objeet  of  these  is  to  temporarily  elose  the 
abdominal  parietes  after  the  uterus  is  opened,  so  as  to  prevent  the  escape 
of  the  intestines,  or  the  entrance  of  blood,  etc.  into  the  peritoneal  cavity. 
Before  incising;  the  uterus  an  assistant  should  carefully  suj)port  it  in  ai 
proper  position,  and  push  it  forward  by  the  hands  placed  on  either  side! 
of  the  incision,  so  as  to  bring  its  surface  into  apposition  with  the  exter-j 
nal  wound  and  ]3revent  the  escape  of  the  intestines.  If  we  have' 
reason  to  believe  that  the  placenta  is  situated  anteriorly,  we  may  incise 
the  uterus  on  one  or  other  side ;  otherwise  the  line  of  incision  should 
be  as  nearly  as  possible  central.  The  substance  of  the  uterus  is  next 
divided  until  the  membranes  are  reached,  which  are  punctured  and 
divided  in  the  same  way  as  the  peritoneum.  The  uterine  incision  should 
be  of  the  same  length  as  that  in  the  abdomen,  and  it  should  not  be  made 
too  near  the  fundus,  for  not  only  is  that  part  more  vascular  than  the 
body  of  the  uterus,  but  wounds  in  that  situation  are  more  apt  to  gape, 
and  do  not  cicatrize  so  favorably.  After  the  uterus  is  opened  Dr.  Lud- 
wia:  Winckel  recommends  that  the  fineers  of  an  assistant  should  be 
placed  in  the  two  terminal  angles  of  the  wound,  so  that  the  ends  of  the 
incision  may  be  hooked  up  and  brought  into  close  apposition  with  the 
abdominal  opening.  By  this  means  he  prevents  not  only  the  escape  of 
blood  and  liquor  amnii  into  the  cavity  of  the  peritoneum,  but  also  the 
protrusion  of  the  abdominal  viscera. 

Removal  of  the  Child. — The  child  should  now  be  carefully  removed, 
the  head  and  shoulders  being  taken  out  (if  possible)  first;  [^]  the  placenta 
and  membranes  are  afterward  extracted.  Should  the  placenta  be  unfor- 
tunately found  immediately  under  the  incision,  a  considerable  loss  of 
blood  is  likely  to  take  place,  which  can  only  be  checked  by  removing 
it  from  its  attachments  and  concluding  the  operation  as  rapidly  as  pos- 
sible. 

Eventration  of  the  Uterus. — As  soon  as  the  child  is  removed  the 
uterus  should  be  turned  out  of  the  abdominal  cavity,  which  is  tempo- 
rarily closed  by  the  sutures  already  introduced,  and  further  protected  by 
placing  a  large  flat  sponge  behind  the  uterus.     At  the  same  time,  hem- 
orrhage is  controlled  by  a  rubber  cord    tied    round    the  cervix.      [Inl 
many  cases  the  uterus  is  turned  out  whole,  the  cervix  is  constricted  by  I 
manual  pressure  or  the  tube  of  Esmarch,  and  then  the  uterus  is  opened  \ 
and  the  foetus  removed.      In  such  operations  the  foetus  is  usually  some-  \ 
what  asphyxiated. — Ed.]     This  gives  time  thoroughly  to  attend  to  the 
suturing   of  the    uterine  incision,  a  point  of  great  importance.     The 
uterus  should  now  be  surrounded  by  soft  napkins  wrung  out  of  warm 
l-iu-2000  perchloride-of-mercury  solution.    After  the  placenta  has  been 
removed  and  the  hemorrhage  arrested  we  should  see  that  the  os  uteri  is 
open,  so  that  any  fluid  in  the  uterine  cavity  may  drain  into  the  vagina. 
The  cavity  should  also  be  dusted  with  iodoform. 

Importance  of  Securing  Uterine  Contraction. — As  soon  as  the 
child  and  the  secundines  have  been  extracted,  the  sooner  the  uterus  con- 
tracts the  better.     It  will  usually  do  so  of  itself,  but  should  it  remain 

[^  We  say  here,  feet  first,  according  to  the  most  experienced  continental  authori- 
ties.— Ed.] 

3i 


530  OBSTETRIC  OPIJRATJOXS. 

lax  ami  flabhv  it  sliould  l)e  pivssL-d  and  sliimilated  hy  the  iiaiid.  We 
arc  spL'cially  warned  against  iiandlin*!;  the  uterus  l>y  Kanishotliuni  and 
others;  hut  there  seems  no  valid  reason  why  we  should  not  restrain 
hemorrhage  in  this  way  as  after  a  natural  labor.  The  intervention  of 
the  abdominal  i)arietes  in  their  lax  condition  after  delivery  can  make 
very  little  diilerence  between  the  two  cases.  Ergot inc  administered 
liyj)odermieally  will  also  be  useful  in  promoting  enieient  contraction. 
Closure  of  the  Uterine  "Wound. — Much  of  the  recent  success  in 
this  operation  is  due  to  the  carefid  closing  of  the  uterine  incision  by 
.sutures.  Sanger,  who  has  paid  great  attention  to  this  point,  strips  off 
the  peritoneum  for  about  five  centimeters  on  each  side  of  the  incision, 
and  then  resects  the  muscular  wall  for  about  two  centimeters.[']  [This 
is  very  rarely  done  now  by  any  oj^erator,  unless  the  peritoneum  is  so 
tightly  adherent  that  it  will  not  slide  over  the  nniscular  coat,  which  is 
seldom  the  case. — Ed.]  This  done,  he  inserts  eight  to  ten  deep  sutures 
of  soft  silver  wire  through  the  peritoneum  aud  muscle,  but  not  through 
the  mucosa,  taking  care  to  turn  in  the  soft  peritoneal  flaps  so  as  to  bring 
them  into  accurate  contact,  Avith  the  view  of  securing  rapid  adhesion. 
The  reason  for  not  passing  the  suture  into  the  uterine  cavity  is  to  pre- 
vent the  possibility  of  sejitic  material  finding  its  way  along  the  track 
of  the  sutures  into  the  peritoneum.  Finally,  he  passes  twenty  to  twenty- 
five  fine  silk  sutures  through  the  inverted  edges  of  the  peritoneum. 
Leopold,  who  saved  sixteen  out  of  nineteen  cases  at  Dresden,  adopts 
much  tlie  same  plan,  but  he  does  not  strip  off  the  peritoneal  flaps  nor 
excise  any  portion  of  the  uterine  walls;  and  his  method  is  certainly 
simpler  and  apparently  quite  as  effectual.  The  provisional  elastic  tub- 
ing may  now  be  removed  aud  the  uterus  replaced  in  the  abdominal 
cavity. 

[Pure  Chinese  silk    is    the    material   generally  preferred  for    both 
the  deep,  and  superficial  uterine  sutures.     The  Lembert  stitches  are  usu- 
ally a   few  more  than   the  deep-seated:  10  or  12  deep,  and  14  to  16 
Lembert,  are  about  the  average.     Silver  wire  is  still  preferred  by  a  few 
operators,  and  chromic  catgut  by  others,  for  the  deep  sutures.      Catgut 
is  not  a  very  safe  material  for  holding  its  knots. — Ed.] 
(  A  point  of  great  importance,  and  not  sufficiently  insisted  on,  is  the 
1  advisability  of  not  closing  the  abdominal  wound  until  we  are  thoroughly 
■  satisfied  that  hemorrhage  is  completely  stopped,  since  any  escape  of 
;  blood  into  the  peritoneum  would  very  materially  lessen  the  chances  of 
recovery.     In  a  successful  case  reported  by  Dr.  Newman-  the  Mound  was 
not  closed  for  nearly  an  hour.     [Where  the  uterus  is  proj)erly  sutured 
there  can  be  no  occasion  for  this  delay.     The  Esmarch  tube  prevents 
blood-loss  while  the  uterine  wound  is  being  closed,  and  the  suture-pres- 
sure prevents  it  after  the  tube  is  taken  off.     Under  the  old  operation  delay 
was  valuable,  but  it  is  not  required  now.   AVe  have  seen  three  successful 
operations  entirely  completed   in  thirty-five,    thirty-two,  and  twenty- 
five  minutes  respectively.     The  great  danger  from  hemorrhage  is  dur- 
ing the  incising  and  evacuating  of  the  uterus  where  the   placenta  is 

[^  These  measures  are  in  error  by  an  oversight.     Five  centimeters  are  nearly  two 
inches,  and  two  are  i|  of  an  incli ;  millimeters  are  intended. — Ed.] 
^  Obst.  Trans.,  1867,, vol.  viii.  p.  o43. 


THE  CjESAREAN  SECTION.  531 

under  the  line  of  incision. — Ed.]  Before  doing  so  all  blood  and  dis- 
charges should  be  carefully  removed  from  the  peritoneal  cavity  by  clean 
soft  sponges  dipped  in  warm  water.  The  abdominal  wound  should  be 
closed  from  above  downward  by  wire  or  silk  sutures,  which  should  be 
inserted  at  a  distance  of  an  inch  from  each  other  and  passed  entirely 
through  the  abdominal  walls  and  the  peritoneum,  at  some  little  distance 
from  the  edges  of  the  incision,  so  as  to  bring  the  two  surfaces  of  the 
peritoneum  into  contact.  [^]  By  this  means  we  ensure  the  closure  of  the 
peritoneal  cavity,  the  opposed  surfaces  adhering  with  great  rapidity.  If, 
as  should  be  the  case,  the  operation  is  performed  with  full  antiseptic  pre- 
cautions, the  wound  should  now  be  dressed  precisely  as  after  ovariotomy. 

Subsequent  Management. — Into  the  subsequent  treatment  it  is 
unnecessary  to  enter  at  any  length,  since  it  must  be  regulated  by  gen- 
eral principles,  each  symptom  being  met  as  it  arises.  It  has  been  cuB-t 
tonTary  to  administer  opiates  freely  after  the  operation,  but  they  seem  to! 
have  a  tendency  to  produce  sickness  and  vomiting,  and  ought  not  to  be' 
exhibited  unless  pain  or  peritonitis  indicates  that  they  are  required.  In 
fact,  the  treatment  should  in  no  way  differ  from  that  usual  after  ovari- 
otomy, and  the  principles  that  should  guide  us  will  be  best  shoMai  by  the 
following  quotation  from  Mr.  Spencer  Wells'  description  of  that  opera- 
tion :  "■  The  principles  of  after-treatment  are — to  obtain  extreme  quiet, 
comfortable  warmtli,  and  perfectly  clean  linen  to  the  patient ;  to  relieve 
pain  by  warm  applications  to  the  abdomen  and  by  opiate  enemas ;  to  give 
stimulants  when  they  are  called  for  by  failing  pulse  or  other  signs  of 
exliaustion;  to  relieve  sickness  by  ice  or  iced  drinks;  and  to  allow  plain, 
simple,  but  nourishing  fobd.  The  catheter  must  be  used  every  six  or 
eight  hours,  until  the  patient  can  move  without  pain.  The  sutures  are 
removed  on  the  third  day,  [^]  unless  tympanitic  distension  of  the  stomach 
or  intestines  endangers  reopening  of  the  wound.  In  such  circumstances 
they  may  be  left  for  some  days  longer.  The  superficial  sutures  may 
remain  until  union  seems  quite  firm." 

Porro's  Operation. — Within  the  last  few  years  an  important  modi- 
fication of  the  Csesarean  section  has  been  adopted,  which  is  generally 
known  as  Porro's  operation,  from  Professor  Porro  of  Pa  via,  who  was 
the  first  European  surgeon  who  practised  it.  In  this  operation,  after 
the  uterus  is  emptied  the  entire  organ  is  drawn  out  of  the  abdominal 
wound  and  excised,  its  neck  being  first  constricted  so  as  to  suppress 
hemorrhage,  the  stump  being  fixed  externally  in  the  manner  of  the 
pedicle  in  ovariotomy.  The  idea  is  by  no  means  new.  It  appears  to 
have  been  first  suggested  by  an  Italian — Dr.  Cavallini — in  1768.  In 
1823  the  late  Dr.  Blundell  made  the  same  proposal,  and  fortified  it  by 
numerous  experiments  on  pregnant  rabbits,  in  the  course  of  which  he 
found  that  he  lost  all  by  the  Csesarean  section,  but  saved  three  out  of  four 
in  which  he  ligatured  and  amputated  the  uterus.  The  suggestion  was 
not,  however,  carried  into  actual  practice  until  Dr.  Storer  of  Boston  in 
1869  removed  the  uterus  in  a  case  of  fibroid  tumor  obstructing  the 
pelvis  and  impeding  delivery. 

\}  American  operators  prefer  to  put  their  sutures  much  nearer  tlian  this,  to  diminish 
the  individual  tension. — Ed.] 
|[*  Rarely  before  the  sixth  to  eighth  in  the  United  States. — Ed.] 


532  OBSTETRIC  OPERATIONS. 

Since  Porro's  first  case  the  operation  has  been  frequently  performed 
on  the  Continent,  with  resuhs  which  are,  on  the  whole,  encouraging. 
The  cases  have  been  carefully  tabulated  by  Dr.  Harris  of  Philadelphia, 
and  more  recently  and  very  comj^letely  by  Dr.  Clement  Godson,'  who 
has  collected  215'  cases,  out  of  which  109,  or  50.6  i)er  cent.,  were  suc- 
cessful as  regards  the  mother,  [Dr.  Godson  is  much  behind  in  his 
record,  as  my  table  has  260  cases  \\\)  to  the  same  date,  with  142  women 
saved.  There  were  89  operations,  with  19  deaths  and  1  suicide,  in  the 
years  1885,  1886,  1887,  and  1888.— Ed.]  The  obvious  advantage  of  _ 
this  plan  is,  that  instead  of  leaving  the  incised  uterus,  with  its  proba-' 
bly  gaping  wound  and  all  the  attendant  risk  of  septic  mischief,  in  the 
abdominal  cavity,  it  is  fixed  externally  and  in  a  position  Avhere  it  can  be 
readily  dressed. 

The  objection  is  that  it  entirely  uusexes  the  patient,  but  in  the  class 
of  women  requiring  the  Csesarean  section  from  pelvic  deformity  it  is 
questionable  whether  this  can  be  fairly  considered  as  a  drawback.  It 
is  perhaps  not  justifiable  to  attempt  as  yet  any  positive  decision  as  to 
the  indications  for  this  plan.  It  certainly  seemed  at  first  to  be  less 
dangerous  than  the  Csesarean  section,  but  the  improved  results  recently 
obtained  in  the  latter  operation  have  shown  how  it  affords  the  patient 
as  good  if  not  a  better  chance,  without  permanent  mutilation.  "  It 
seems  probable,  therefore,  that  in  future  the  Porro  operation  will  be 
chiefly  adopted  when  for  some  reason,  such  as  the  existence  of  fibro- 
myoraata,  the  ablation  of  the  uterus  is  specially  indicated."  [We 
believe  that  the  Porro  operation  will,  in  all  probability,  meet  Avith 
better  success  than  the  "  conservative  "  method  in  Great  Britain,  from 
the  fact  that  the  last  five  cases  in  order  have  all  recovered.  Holding 
the  views  there  generally  advocated,  the  section  M'ill  only  be  made  in 
badly-deformed  rachitic  dwarfs  and  in  the  subjects  of  malacosteon, 
which  are  much  more  frequently  thus  delivered  than  the  former. 
These  will  probably  do  better  under  the  exsective  method,  which 
besides  has  the  advantage  that  it  sometimes  cures  malacosteon,  as  shown 
by  the  results  in  continental  Europe. — Ed.]  The  operation  in  the  suc- 
cessful cases  has  been  performed  M'ith  full  antiseptic  precautious,  and 
the  neck  of  the  uterus,  after  the  organ  is  emptied,  carefully  secured  by 
ligatures  before  its  body  is  amputated.  Some  operators  have  encircled 
the  neck  of  the  uterus  Avith  a  chain  or  wire  ecraseur  before  removing 
it,  and  by  this  means  completely  controlled  hemorrhage.  Richardson  ^ 
transfixed  the  neck  of  the  uterus  with  two  large  pins  crossing  each 
other  before  removing  the  wire  of  the  ecraseur,  and  encircled  it  with 
stout  carbolized  cord.  Miiller  of  Berne  has  rcconnncndcd  that  the  entire 
uterus  shoidd  l)e  turned  out  of  the  abdominal  cavity  through  a  long 
incision  before  it  is  emptied,  so  as  to  avoid  the  risk  of  its  fluid  contents 
entering  the  abdomen  ;  but  this  manoeuvre  has  not  always  proved  feasi- 
.ble.  The  pedicle  has  generally  been  fixed  in  the  lower  angle  of  the 
abdominal  wound  and   dressed  antiseptically.     In  most  cases  one  or 

'  "  Form's  Operation,"  Brit.  Med.  Journ.,  1884,  vol.  i.  p.  142. 

*  Dr.  Godson  has  kindly  made  up  these  figures  for  rue  up  to  the  present  date  (Janu- 
ary, 1889). 

^American  Journ.  of  Med.  Science,  1881. 


THE  CESAREAN  SECTION.  533 

more  drainage-tubes  have  been  used,  either  through  Douglas'  space  or 
ill  the  abdominal   wound. 

Symphysiotomy. — Bearing  in  mind  the  great  mortality  attending 
the  Ciesarean  section,  it  is  not  surprising  that  obstetricians  should  have 
anxiously  considered  the  possibility  of  devising  a  substitute  which 
should  afford  the  mother  a  better  chance  of  recovery.  The  first  pro- 
posal of  the  kind  was  one  from  which  great  results  were  at  first  antici- 
pated. In  1768,  Sigault,  then  a  student  of  medicine  at  Angers,  sug- 
gested symphyHiotom.}!,  which  consists  in  the  division  of  the  symphysis 
pubis  with  a  view  of  allowing  the  pubic  bones  to  separate  sufficiently 
to  admit  of  the  passage  of  the  child.  [The  idea  was  not  original, 
but  came  from  reading  the  work  of  Severin  Pineau,  who  suggested 
it. — Ed.]  Although  at  first  strongly  opposed,  it  was  subsequently 
ardently  advocated  by  many  obstetricians,  and  was  often  performed  on 
the  Continent  and  in  a  few  cases  in  England.  [^] 

It  is  generally  admitted  that  it  is  quite  impossible  to  make  this  a  substi- 
tute for  the  Cajsarean  section,  since  the  utmost  gain  which  a  wide  sep- 
aration of  the  symphysis  pubis  would  give  would  be  altogether  insuffi- 
cient to  admit  of  the  passage  of  even  a  mutilated  foetus.  Dr.  Churchill 
concludes  that  if  it  were  possible  to  separate  it  to  the  extent  of  four 
inches,  we  should  only  have  an  increase  of  from  four  lines  to  half  an 
inch  in  the  antero-posterior  diameter,  in  which  the  obstruction  is  gen- 
erally most  marked.  In  the  lesser  degrees  of  deformity  this  might 
possibly  be  sufficient  to  allow  the  foetus  to  pass,  but  the  risk  of  the 
operation  itself,  and  the  subsequent  ill  effects,  P]  altogether  contra- 
indicate  it  in  cases  of  this  description. 

[As  the  Neapolitan  advocates  of  symphysiotomy  do  not  advise  its 
performance  in  cases  with  a  conjugate  of  less  measure  than  67  milli- 
meters, or  2f  inches,  it  is  not  adapted  to  extreme  pelvic  deformities, 
and  cannot  take  the  place  of  the  Csesarean  section.  The  design  of  the 
operation  is  to  avoid  craniotomy  in  cases  where  the  forceps  cannot  be 
made  effective,  and  where  a  moderate  increase  of  pelvic  space  will 
enable  a  mother  to  deliver  herself  of  a  living  foetus.  The  first  50 
operations  after  the  revival  in  Naples  in  1866  saved  40  women  and 
41  children. — Ed.] 

['Once  only  by  Mr.  Jolm  Welcliman  of  Kingston,  Eng.,  in  1782. — Ed.] 

['■'Prof.  Ottavio  Morisani  of  Naples,  tlie  best  living  authority,  denies  the  existence 

of  the   "  subsequent "   ill  effects  claimed  by  Robert  Barnes  and  others  in  England. 

Women  have  been  twice  operated  upon  with  success. — Ed.] 


534  OBSTETRIC  OPERATIONS. 


CHAPTER   VII. 

LAPAKO-ELYTKOTOMY. 

In  the  early  etlitions  of  this  Avork  laparo-elytrotomy  was  Ijriofly 
CO  II. side  red  as  one  of  the  suggested  substitutes  for  the  ("lesarean  section 
Mhieh  merited  careful  study  and  a])peared  to  he  of  a  promising  chara<-- 
ter,  but  of  which  too  little  Mas  known  to  justify  any  positive  conchi- 
sions  with  regard  to  it.  The  subject  naturally  attracted  considerable 
attention,  and  several  interesting  papers  have  appeared  in  Avhich  its 
indications,  difficulties,  and  advantages  have  been  carefully  considered. 
Since  Thomas'  first  case  was  })ublislK'd  several  operations  have  been 
performed,  with  results  so  encouraging  that  I  cannot  but  believe  that 
the  ojieration  has  a  i'uture  before  it,  and  that  it  may  sometimes  be 
resorted  to  instead  of  the  more  hazardous  Csesareau  section  unless  some 
special  contraindication  exists.  Under  these  circumstances  it  seems 
proper  no  longer  to  consider  it  as  an  addendum  to  the  description  of 
the  Cfesarean  section,  but  to  study  it  more  in  detail  in  a  separate 
chapter. 

History. — The  history  of  the  operation  is  curious  and  interesting. 
The  earliest  suggestion  of  a  procedure  of  this  character  seems  to  have 
been  made  by  joerg  in  the  year  1806,  who  proposed  a  modified  Cesa- 
rean section,  without  incision  of  the  uterus,  by  the  division  of  the  linea 
alba  and  of  the  upper  part  of  the  vagina,  the  foetus  being  extracted 
through  the  cervix.  Tliis  suggestion  was  never  carried  into  practice, 
and  it  is  obvious  that  it  misses  the  one  chief  advantage  of  lai>aro- 
elytrotomy,  the  leaving  of  the  peritoneum  intact.  In  1820,  Kitgeu 
proposed  and  actually  attempted  an  o])eration  much  resembling 
Thomas',  in  which  section  of  the  peritoneum  was  avoidal.  He 
failed,  however,  to  complete  it,  and  was  eventually  compelled  to 
deliver  his  patient  by  the  CVesarean  section.  In  1S2.'>,  Baudcl()c(|ue 
the  younger  independently  conceived  the  same  idea,  and  actually  car- 
ried it  into  practice,  although  without  success.  Lastly,  in  1837,  Sir 
Charles  Bell  suggested  a  similar  operation,  clearly  ])erceiving  its  advan- 
tages. Hence  it  appears  that  previous  to  Thomas'  recent  work  in  the 
matter  the  operation  was  independently  invented  no  less  than  three  times. 
It  fell,  however,  entirely  into  oblivion,  and  was  only  occasionally  men- 
tioned in  systematic  works  as  a  matter  of  curious  obstetric  history,  no 
one  ajipareutly  aj)preciating  the  promising  character  of  the  procedure. 

In  the  year  1870,  Dr.  T.  Gaillard  Thomas  of  New  York  read  a 
paper  before  the  ^ledical  Association  of  the  town  of  Yonkers  on  the 
Hudson  River  entitled  "  Gastro-elytrotomy  a  Substitute  f()r  the  i'vosa- 
rean  Section,''  in  which  he  descril)ed  the  operation  as  he  had  jierformed 
it  three  times  on  the  dead  subject,  and  once  on  a  married  woman  in  1870, 
with  a  successful  issue  as  regards  the  child.    It  seems  bcvond  doubt  that 


LArARO-EL  YTROTOMY.  535 

Thomas  invented  the  operation  for  himself",  being  ignorant  of  Ritgen's 
and  Baudelo('(|uc''s  previous  attempts,  and  it  is  eertain,  to  quote  Gar- 
rigues/  that  to  him  "  belongs  the  glory  of  having  Ijeen  the  first  who 
performed  gastro-elytrotomysoas  to  extract  a  living  child  from  a  living 
mother  in  his  first  operation,  and  of  having  brought  both  mother  and 
child  to  complete  recovery  in  his  second  operation." 

Since  Thomas'  first  case  the  operation  has  been  performed  four  times 
by  Dr.  Skene  of  Brooklyn,  and  has  found  its  way  across  the  Atlantic, 
having  been  performed  by  llime  in  Sheffield,  Ed  is  in  London,  and 
Poullet  in  Lyons. 

[Laparo-elytrotomy  has  been  performed  14  times  with  7  recoveries: 
5  children  were  dead ;  1  died  in  an  hour ;  1  died  in  eighteen  days,  and  7 
are  recorded  as  "  saved."  In  successful  issue  it  is  now  much  behind  the 
average  of  the  Sanger  and  Porro  operations  of  the  last  four  years. — Ed.] 

Nature  of  the  Operation. — The  object  of  laparo-elytrotomy  is  to 
reach  the  cervix  by  incision  through  the  lower  part  of  the  abdominal, 
wall  and  upper  part  of  the  vagina,  aud  through  it  to  extract  the  foetus ( 
as  may  most  easily  be  done. 

Advantages  over  the  Caesarean  Section. — If  this  procecUire  is 
found  practicable,  the  enormous  advantages  it  offers  over  the  Csesareaa 
section  are  at  once  apparent,  since  in  dividing  the  abdomen  the  ab- 
dominal wall  only  is  incised  and  the  peritoneum  is  left  intact.  The 
vagina  is  divided,  but  incision  of  the  uterine  parietes,  which  forms 
one  of  the  chief  risks  of  the  Cesarean  section,  is  entirely  avoided.  Now 
there  is  nothing  in  either  of  these  procedures  alarming  in  itself,  and  if 
further  experience  proves  that  the  practical  difficulties  of  the  operation 
do  not  stand  in  the  way  of  its  adoption.  Dr.  Thomas  will  have  intro- 
duced by  his  able  advocacy  of  the  operation  probably  the  greatest 
improvement  in  modern  obstetrics.  / 

Cases  Suitable  for  the  Operation.— ^It  may  be  broadly  stated  that 
laparo-elytrotomy  is  applicable  in  all  cases  calling  for  the  Cesarean  sec- 
tion when  the  mother  is  alive.  ;In  post-mortem  extractions  of  the  fetus 
the  Cnesarean  section,  being  the  most  rapid  procedure,  would  certainly 
be  preferable.:  Exceptions  must  be  made  for  certain  cases  of  morbid 
conditions  of  the  soft  parts  which  render  delivery  per  vias  naturales 
impossible,  and  in  which  laparo-elytrotomy  could  not  be  performed,  as 
in  cases  of  tumor  obstructing  the  pelvic  cavit)',  also  in  carcinoma  or 
fibroid  of  the  uterus.]  When  the  head  is  firiuly  impacted  in  the  pelvic 
brim  and  cannot  be  dislodged,  the  operation  would  be  impossible,  as  the 
vagina  could  not  be  incised.  [In  more  than  25  per  cent,  of  American 
Csesareau  cases  laparo-elytrotomy  was  certainly  inapplicable.  It  was 
probably  so  in  a  number  more,  perhaps  in  all  nearly  one-third. — Ed.] 
Unlike  the  Cesarean  section,  the  oj)eration  cannot  be  performed  twice 
n  the  same  patient,  at  least  on  the  same  side,  since  adhesions  left  by 
the  former  incisions  would  prevent  the  separation  of  the  peritoneum 
and  division  of  the  vagina.]  It  remains  to  be  seen  whether  in  certain 
cases  of  extreme  deformity,  with  pendulous  abdomen  and  distorted 
thighs,  the  site  of  incision  might  not  be  so  difficult  to  reach  as  to  ren- 
der the  necessary  manoeuvres  im]>ossible. 

'  New  York  Mai.  Jonrn.,  1878,  vol.  xxviii.  pp.  337,  449. 


^ 


536  OBSTETRIC  OPERATIONS. 

Anatomy  of  the  Parts  concerned  in  the  Operation. — It  will 
facilitate  the  proper  comprehension  of  the  operation,  and  i-ender  an 
avoidance  of  its  possi])]e  dangers  more  easy,  if  the  anatomical  relations 
of  the  parts  concerned  are  bi'iefly  described. 

The  abdominal  incision  extends  from  a  j)oint  an  inch  above  the  ante- 
rior superior  iliac  spine,  and  is  carried,  with  a  sliglit  <h)\vnward  cni've, 
]>arallel  to  Pon])art's  ligaments  until  it  reaches  a  point  one  inch  and 
three-quarters  above,  and  to  the  outside  of,  the  spine  of  the  j)ul)es. 
Beyond  the  latter  point  it  must  not  extend,  so  as  to  avoid  the  risk  of 
wounding  the  round  ligament  and  the  epigastric  artery.  In  this  incis- 
ion the  skin,  the  aj)oneurosis  of  the  external  oblique,  and  the  fibres  of 
the  internal  oblique  and  transversalis  muscles  are  divided.  The  rectus 
is  not  implicated.  After  the  muscles  are  divided  the  transversalis  fascia 
i$  reached.  It  is  fortunately  rather  dense  in  this  situation,  and  is  sep- 
arated from  the  peritoneum  by  a  layer  of  connective  tissue  containing 
fat. 

The  superficial  epigastric  artery  is  necessarily  divided,  but  is  too 
small  to  give  any  trouble.  The  internal  epigasti-ic  is  fortunately  not 
divided,  but  is  so  near  the  inner  end  of  the  incision  that  it  may  acci- 
dentally be  so.  In  one  of  Dr.  Skene's  operations  it  was  laid  bare. 
Starting  from  the  external  iliac  about  a  quarter  of  an  inch  above  Pou- 
jiart's  ligament,  it  runs  dow'u ward,  forward,  and  inward  to  the  ligament, 
thence  it  turns  upward  and  inward,  in  front  of  the  round  ligament  and 
to  the  inner  side  of  the  internal  abdominal  ring,  behind  tlie  jiostcrior 
layer  of  the  sheath  of  the  rectus  nuiscle,  which  it  finally  enters.  The 
circumflex  iliac  arten;  also  rises  from  the  external  iliac  a  little  below 
the  epigastric.  It  runs  between  the  peritoneum  and  Poupart's  ligament 
until  it  reaches  the  crest  of  the  ilium,  to  the  inner  side  of  which  it  runs. 
It  thus  lies  altogether  below  the  line  of  the  incision,  and  is  not  likely 
to  be  injured. 

After  the  transversalis  fascia  is  divided  the  peritoneum  is  reached, 
and  is  readily  lifted  up  intact,  so  as  to  expose  the  ujiper  part  of  the 
vagina,  through  which  the  fcctus  is  extracted.  It  is  fortunate,  as  facil- 
itating this  manoeuvre,  that  the  peritoneum  is  much  morgja-x  than  in 
the  non-pregnant  state,  and  it  has  been  found  very  easy  to  lift  it  out  of 
the  way  in  all  the  operations  hitherto  performed. 

The  division  of  the  vagina  is  the  part  of  the  operation  likely  to  give 
rise  to  most  trouble  and  risk.  It  is  to  be  noted  that  in  cases  of  pelvic 
contraction  calling  for  this  operation  the  uterus  with  its  contents  will  be 
almormally  high  and  altogether  above  the  pelvic  brim ;  the  vagina  is 
therefore  necessarily  elongated  and  brought  more  readily  within  reach. 
It  is  enlarged  in  its  upper  part  during  jiregnancy,  and  thrown  into 
folds  rcadv  f"or  dilatation  during  the  passage  of  the  child.  It  is  k>osely 
.surrounded  by  the  other  tissues,  and  is  composed  of  muscular  fibres 
easily  separable  and  an  internal  mucous  layer.  Its  vascular  arrange- 
ments are  very  complex,  and  the  risk  of  hemorrhage  is  one  of  the  prom- 
inent difficulties  of  the  oju'ration. 

In  Baudelocque's  attem])t,  in  which  the  vagina  was  cut  instead  of 
torn,  the  loss  of  blood  was  so  great  as  to  lead  to  a  discontinuance  of 
the  operation.     The  arteries  are  numerous,  consisting  of  l)ranches  from 


LAPARO-ELYTROTOMY.  537 

the  hypogastric,  inferior  vesical,  uiternal  piidic,  and  hemorrhoidal.  The 
veins  form  a  network  surrounding  the  whole  canal,  but  are  largest  at 
its  extremities,  so  that  it  is  desirable  to  open  the  vagina  as  low  down  as 
possible. 

Behind  the  vagina  lies  the  pouch  of  peritoneum  known  as  Douglas' 
space,  and  below  that  the  rectum.  In  front  of  it  lies  the  bladder,  and 
the  risk  of  injuring  that  viscus  or  the  ureter  entering  it  constitutes 
another  of  the  dangers  of  the  operation.  The  relations  of  these  jiarts 
have  been  specially  studied  by  Garrigues  ^  with  the  view  of  facilitating 
the  safe  performance  of  the  operation,  and  I  quote  his  description  : 

"  The  anterior  superior  surface  of  the  vagina  is  in  its  upper  part 
bound  by  loose  connective  tissue  to  the  bladder  on  a  surface  that  has 
the  shape  of  a  heart.  In  the  lower  or  anterior  part  the  boundary-line 
of  this  surface  runs  parallel  to,  and  a  little  outside  of,  the  tngonum  vesi- 
cale.  In  the  upper  part  it  follows  the  outline  of  the  vagina,  from  which 
it  passes  over  to  the  cervix.  The  distance  from  the  internal  opening  of 
the  urethra  to  the  neck  of  the  womb  is  one  inch  and  a  quarter  (3.2 
centimeters).  The  bladder  extends  five-eighths  of  an  inch  (1.5  centi- 
meters) upon  the  cervix.  It  is  very  liable  to  be  reached  by  the  vaginal 
rent  if  the  latter  is  made  too  high  up  or  too  horizontal.  The  lower 
part  of  the  antero-superior  wall  carries  in  the  middle  line  the  urethra. 
In  the  uppermost  part,  a  little  outside  of  and  behind  the  bladder,  lies 
the  ureter.  In  order  to  avoid  the  ureter  and  the  bladder  the  incision 
of  the  vagina  should  be  made  nearly  an  inch  and  a  half  (3.8  centime- 
ters) below  the  uterus,  and  in  a  direction  parallel  to  the  ureter  and  the 
boundary-line  between  the  bladder  and  the  vagina." 

The  Operation. — The  operation  has  hitherto  been  performed  on  the 
right  side  only.  In  consequence  of  the  position  of  the  rejctum  on  the 
left,  it  seems  doubtful  if  the  difficulties  of  performing  it  on  that  side 
would  not  render  the  operation  impossible.  This  point  can  only  be 
cleared  up  by  experience,  and  in  the  mean  time  the  right  side  should 
certainly  be  selected.  [This  is  an  error,  as  the  operations  of  Hime  of 
Sheffield,  Dandridge  of  Cincinnati,  and  Poullet  of  Lyons,  in  1878, 
1883,  and  1885,  respectively,  were  all  performed  upon  the  left  side.  In 
no  case  of  the  three  was  the  bladder  injured. — Ed.]  For  the  proper 
performance  of  the  operation  four  assistants  are  necessary,  besides  one 
who  administers  the  ansesthetic.  The  patient  is  placed  on  her  back  on 
the  o})erating-table,  with  the  j)elvis  raised  and  in  the  same  position  as 
for  ovariotomy.  In  consequence  of  access  of  air  jx'r  rar/iitam  strict 
antiseptic  precautions  cannot  be  ado[>ted.  Before  commencing  the  ope- 
ration the  cervix  is  dilated  as  nuich  as  possible  by  Barnes'  bags,  assisted, 
if  necessary,  by  digital  dilatation. 

The  ojierator  stands  on  the  right  side  of  the  patient,  while  an  assistant, 
standing  on  her  left,  lays  his  hand  on  the  uterus  and  draws  it  upward  and 
to  the  left,  so  as  to  put  the  skin  on  the  stretch.  The  incision  is  com- 
menced at  a  point  one  inch  above  the  anterior  superior  spine  of  the 
ilium,  and  is  carried  inward  in  a  slightly  curved  direction  until  it 
reaches  a  point  one  and  three-quarter  inches  above  and  outside  the  spine 
of  the  pubes.    The  skin  and  nuiscular  and  aponeurotic  tissues  are  care- 

'  Loc.  ciL,  p.  479. 


538  OBSTETRIC  OPERATIONS. 

I'ully  divided  layer  bv  layer,  any  arterial  hranehes  beiug  seeured  as  they 
are  .severed,  until  the  transverssdis  fascia  is  reached.  This  is  raised  by 
a  fine  tenaculum,  and  an  aperture  is  made  in  it  through  which  a  dii-ec- 
tor  is  introduced,  and  on  this  the  i'aseia  is  divided  in  the  whole  length 
of  the  superficial  incision.  The  operator  now  separates  the  peritoneum 
from  the  transversalis  and  iliac  fascia  with  his  fingers,  and  an  assistant, 
placed  on  his  left,  elevates  it,  as  well  as  the  contained  intestines,  by 
means  of  a  fine  warmed  napkin,  and  keeps  it  well  out  of  the  way  during 
the  rest  of  the  operation.  A  third  assistant  now  introduces  a  silver 
catheter  into  the  bladder,  and  holds  it  in  the  position  of  the  boundary- 
line  between  it  and  the  vagina,  and  below  the  uterus. 

A  blunt  wooden  instrument  like  the  obturator  of  a  speculum  is  intro- 
duced into  the  vagina,  which  is  pushed  up  by  it  above  the  ilio-])ectineal 
line.  On  this  an  incision  is  made  by  Pacj^uelin's  thermo-cautery  heated 
to  a  red  heat  only,  as  fir  below  the  uterus  as  possible,  and  parallel  to 
the  ilio-pectineal  line  and  the  catheter  felt  in  the  bladder.  When  the 
vagina  has  been  burnt  through,  the  index  fingers  of  both  hands  are 
pushed  through  the  incision,  and  the  vagina  torn  through  as  far  forward 
as  is  deemed  safe  by  the  guide  of  the  catheter  in  the  bladder,  and  as 
far  backward  as  possible.  When  this  has  been  done  the  uterus  is 
depressed  to  the  left,  and  the  cervix  lifted  into  the  incision  by  the 
fingers,  and  the  membranes  are  ruptured.  Through  the  cervix  thus 
elevated  the  child  is  extracted,  according  to  the  presentation,  either  by 
simple  traction  by  the  forceps  or  by  turning.  Before  concluding  the 
oj)eration  the  bladder  should  be  injected  with  milk  to  make  sure  that  it 
has  not  been  wounded.  \  Should  it  be  so,  the  laceration  may  be  at  once 
united  by  carbolized  gut.  The  principal  risk  at  this  stage  is  hemorrhage 
from  the  vaginal  vessels,  which,  however,  fortunately,  did  not  give  rise 
to  much  trouble  in  any  of  the  recent  operations.  If  it  occurs  it  must  be 
dealt  with  as  best  Me  can,  either  by  ligature,  by  the  actual  cautery,  or  by 
thoroughly  plugging  the  vaginal  wound  with  cotton-wool  both  through 
the  incision  and  per  raghwm.  If  the  latter  be  not  nece&sary,  the  wound 
should  be  cleaned  by  injecting  a  warm  solution  of  weak  carbolized  water 
(2  per  cent.},  its  edges  united  by  iuterru])tcd  sutures,  and  dressed  as  is 
deemed  best.  The  subsequent  treatment  must  be  conducted  on  general 
surgical  principles,  and  will  much  resemble  that  necessary  after  other 
severe  abdominal  operations,  such  as  ovariotomy.  The  vagina  should  be 
gently  syringed  two  or  three  times  daily  with  a  weak  antiseptic  lotion. 
The  diet  should  be  light  and  nutritious,  chiefly  consisting  of  milk,  beef- 
tea,  and  the  like.  Pain,  jn'rexia,  etc.  must  be  treated  as  they  arise. 
[In  the  I'ace  for  supremacy  lajiaro-elytrotomy  has  been  left  far  in  the 
rear  by  the  Sanger-Ctesarean  and  Porro-Oesarcan  operations.  The  last 
laparo-elytrotomy  on  record  was  performed  on  September  18,  1887, 
since  which  date  we  have  reports  of  82  Sanger  ca.ses  with  14  deaths, 
and  29  Porro  cases  with  3  deaths.  It  looks  as  if  the  operation  of  Prof. 
Thomas  was  not  in  favor, — Ed.] 


THE  TEAJS'SFUSION   OF  BLOOD.  .  539 


CHAPTER  VIII. 

THE  TRANSFUSION  OF  BLOOD. 

The  transfusion  of  blood  in  desperate  and  apparently  hopeless 
cases  of  hemorrhage  offers  a  possible  means  of  rescuing  the  patient 
which  merits  careful  consideration.  It  has  again  and  again  attracted 
the  attention  of  the.  profession,  but  has  never  become  popularized  in 
obstetric  practice.  The  reason  of  this  is  not  so  much  the  inherent 
defects  of  the  operation  itself — for  quite  a  sufficient  number  of  success- 
ful cases  are  recorded  to  make  it  certain  that  it  is  occasionally  a  most 
valuable  remedy — but  the  fact  that  the  operation  has  been  considered 
a  delicate  and  difficult  one,  and  that  it  has  been  deemed  necessary  to 
employ  a  complicated  and  expensive  apparatus  which  is  never  at  hand 
when  a  sudden  emergency  arises.  Whatever  may  be  the  difference  of 
opinion  about  the  value  of  transfusion,  I  think  it  must  be  admitted  that 
it  is  of  the  utmost  consequence  to  simplify  the  process  in  every  possible 
way,  and  it  is  above  all  things  necessary  to  show  that  the  steps  of  the 
operation  are  such  as  can  be  readily  performed  by  any  ordinarily  quali- 
fied practitioner,  and  that  the  apparatus  is  so  simple  and  portable  as  to 
make  it  easy  for  any  obstetrician  to  have  it  at  hand.  There  are  com- 
paratively few  who  would  consider  it  worth  while  to  carry  about  with 
them,  in  ordinary  every-day  work,  cumbrous  and  expensive  instruments 
which  may  never  be  required  in  a  lifelong  practice  ;  and  hence  it  is  not 
unlikely  that  in  many  cases  in  which  transfusion  might  have  proved 
useful  the  opportunity  of  using  it  has  been  allowed  to  slip.  Of  late 
years  the  operation  has  attracted  ranch  attention,  the  method  of  per- 
forming it  has  been  greatly  simplified,  and  I  think  it  will  be  easy  to 
prove  that  all  the  essential  apparatus  may  be  purchased  for  a  few 
shillings,  and  in  so  portable  a  form  as  to  take  up  little  or  no  room, 
so  that  it  may  be  always  carried  in  the  obstetric  bag  ready  for  any 
possible  emergency. 

History  of  the  Operation. — The  history  of  the  operation  is  of  con- 
siderable interest.  In  Villari's  Life  of  Savonarola  it  is  said  to  have  been 
employed  in  the  case  of  Pope  Innocent  VIII.  in  the  year  1492,  but  I 
am  not  aware  on  what  authority  the  statement  is  made.  The  first 
serious  proposals  for  its  performance  do  not  seem  to  ha\'e  been  made 
until  the  latter  half  of  the  seventeenth  century.  It  Mas  first  actually 
performed  in  France  by  Denis  of  Montpellier,  although  Lower  of 
Oxford  had  previously  made  experiments  on  animals  which  satisfied 
him  that  it  might  be  undertaken  with  success.  In  November,  1667, 
some  months  after  Denis'  case,  Lower  made  a  public  experiment  at 
Arundel  House  in  which  twelve  ounces  of  sheep's  blocxl  were  injected 
into  the  veins  of  a  healthy  man,  who  is  stated  to  have  been  very  well 
after  the   operation,  which   must,  therefore,   have   proved  successful. 


540  OBSTETRIC  OPERATIONS. 

These  nearly  siiiinltaneous  cases  gave  rise  to  a  controversy  as  to  priority 
of  invention,  which  was  long  carried  on  with  much  bitterness. 

The  idea  of  resorting  to  transfusion  after  severe  heniori'hage  does  not 
seem  to  have  l)een  then  entertained.  It  was  recommended  as  a  means 
of  treatment  in  various  diseased  states  or  witli  the  extravagant  liope  of 
imparting  new  life  and  vigor  to  the  old  and  decrepit.  The  hlood  (jf  the 
lower  animals  only  was  used  ;  and  under  these  circumstances  it  is  not 
surprising  that  the  operation,  although  practised  on  several  occasions, 
was  never  established  as  it  might  have  been  had  its  indications  been 
better  understood. 

From  that  time  it  fell  almost  entirely  into  ol^livion,  although  experi- 
ments and  suggestions  as  to  its  applicability  were  occasionally  made, 
especially  by  Dr.  Harwood,  professor  of  anatomy  at  Cambridge,  who 
published  a  thesis  on  the  subject  in  the  year  1785.  He,  however,  never 
carried  his  suggestions  into  practice,  and,  like  his  predecessors,  only 
proposed  to  emjiloy  blood  taken  from  the  lower  aniiuals.  In  the  year 
1824,  Dr.  Blimdell  published  his  well-known  work,  entitled  Be.'<earcJie><, 
Physiological  and  Pathological,  which  detailed  a  large  number  of  experi- 
ments ;  and  to  that  distinguished  physician  belongs  the  undoubted  merit 
of  having  brought  the  subject  prominently  before  the  profession,  and 
of  pointing  out  the  cases  in  which  the  operation  might  be  performed  with 
hopes  of  success.  Since  the  publication  of  this  work  transfusion  has 
been  regarded  as  a  legitimate  operation  under  special  circumstances; 
but,  although  it  has  frequently  been  performed  with  success  and  in  spite 
of  many  interesting  monographs  on  the  subject,  it  has  never  become  so 
established  as  a  general  resource  in  suitable  cases  as  its  advantages  would 
seem  to  warrant.  Within  the  last  few  years  more  attention  has  been 
paid  to  the  subject,  and  the  writings  of  Pauum,  Martin,  and  De  Beliua 
abroad,  and  of  Higginsou,  McDonnell,  Hicks,  Aveling,  and  Schiifisr  at 
home,  amongst  others,  have  thrown  much  light  on  many  points  con- 
nected with  the  operation. 

Nature  and  Object  of  the  Operation. — Trransfusion  is  practically 
only  employed  in  cases  of  profuse  hemorrhage  connected  with  labor,J 
although  it  has  been  suggested  as  possibly  of  value  in  certain  other 
puerperal  conditions,  such  as  eclampsia  or  puerperal  fever.  Theo- 
retically, it  may  be  expected  to  be  useful  in  such  diseases ;  but  inas- 
much as  little  or  nothing  is  known  of  ics  practical  effects  in  these 
diseased  states,  it  is  only  possible  here  to  discuss  its  use  in  cases  of 
excessive  hemorrhage.  Its  action  is  probably  twofold  :  1st,  the  actual 
restitution,of  JMood  which  has  been  lost ;  2d,  the  sujiply  of  a  sufficient 
quantity  of  blood  to  stimulate  the  heart  to  contraction,  and  thus  to 
enable  the  circulation  to  be  carried  on  until  fresh  blood  is  formed. 
The  influence  of  transfusion  as  a  means  of  restoring  lost  blood  must 
be  trivial,  since  the  quantity  required  to  produce  an  effect  is  generally 
very  small  indeed,  and  never  sufficient  to  counterbalance  that  which 
has  been  lost.  Its  stimulant  action  is  no  doubt  of  far  more  imjiort- 
ance;  and  if  the  operation  be  performed  before  the  vital  energies  are 
entirely  exhausted,  the  effect  is  often  most  marked. 

Use  of  Blood  taken  from  the  Lower  Animals. — In  the  earliest 
operations  the  blood  used  was  always  that  of  the  lower  animals,  gen- 


THE  TRANSFUSION  OF  BLOOD.  541 

erally  of  the  sheep.  It  has  been  thought  by  Brown-Sequard  and 
others  that  the  blood  of  sonic  of  the  lower  animals,  especially  of  those 
in  which  the  corpuscles  are  of  smaller  size  than  in  man,  as  of  the  sheep, 
might  be  used  in  safety,  [)rovided  it  is  not  too  rich  in  carbonic  acid  and 
too  poor  in  oxygen,  and  injected  in  small  quantity  only.  /Landois,' 
however,  has  conclusively  proved  that  the  blood  of  any  of  the  lower 
.  animals  has  a  most  injurious  effect  on  the  human  red  corpuscles,  which 
rapidly  become  swollen  and  decolorized,  and  discharge  thejLr..-Coloring 
matter  into  the  serum.  It  is  certain,  therefore,  that  this  plan  cannot 
be  adopted  in  practice.  / 

The  great  practical  difficulty  in  transfusion  has  always  been  the  coagu- 
lation of  the  blood  very  shortly  after  it  has  been  removed  from  thelBody. 
WlTen  fresh-drawn  blood  is  exposed  to  the  atmosphere  the  fibrin  com- 
mences to  solidify  rapidly,  generally  in  from  three  to  four  minutes, 
sometimes  much  sooner.  It  is  obvious  that  the  moment  fibrination 
has  commenced  the  blood  is,  ipso  facto,  unfitted  for  transfusion,  not 
only  because  it  can  be  no  longer  passed  readily  through  the  injecting 
apparatus,  but  because  of  the  great  danger  of  propelling  small  masses 
of  fibrin  into  the  circulation,  and  thus  causing  embolism.  Hence,  if 
no  attempt  be  made  to  prevent  this  difficulty  it  is  essential,  no  matter 
wdiat  apparatus  is  used,  to  hurry  on  the  operation  so  as  to  inject  before 
fibrination  has  begun.  This  is  a  fatal  objection,  for  there  is  no  opera- 
tion in  the  whole  range  of  surgery  in  which  calmness  and  deliberation 
are  so  essential,  the  more  so  as  the  surroundings  of  the  patient  in  these 
unfortunate  cases  are  such  as  to  tax  the  presence  of  mind  and  coolness 
of  the  practitioner  and  his  assistants  to  the  utmost. 

All  the  recent  improvements  have  had  for  their  object  the  avoidance 
of  coagulation,  and  practically  this  has  been  effected  in  one  of  three 
ways:  1^  by /immediate  transfusion  from  arm  to  arni,  without  allow- 
ing the  blood  to'be  exposed  to  the  atmosphere,  according  to  the  methods 
proposed  by  Aveling,  Roussel,  and  Schiifer ;  2d,  by  adding  to  the  blood 
chemical  reagents  which  have  the  property  of  preventing  coagulation; 
3d,  removal  of  the  fibrin  entirely  by  promoting  its  coagulation  and 
straining  the  blood,  so  that  the  liquor  sanguinis  and  blood-corpuscles 
alone  are  injected. 

Inasmuch  as  the  success  of  the  operation  altogether  depends  on  the 
method  adopted,  it  will  be  well,  before  going  further,  to  consider  briefly 
the  advantages  and  disadvantages  of  each  of  these  plans. 

Aveling-'s  Method. — The  method  of  immediate  transfusion  has  been 
brought  prominently  before  the  profession  by  Dr.  Aveling,  who  has 
invented  an  ingenious  apparatus  for  performing  it.  The  apparatus 
consists  essentially  of  a  minature  Higginson's  syringe  without  valves, 
and  with  a  small  silver  canula  at  either  end.  One  canula  is  inserted 
into  the  vein  of  the  person  supplying  blood,  the  other  into  a  vein  of 
the  patient,  and  by  a  curious  manipulation  of  the  syringe,  subsequently 
to  be  described,  the  blood  is  carried  from  one  vein  into  the  other.  It 
must  be  admitted  that  if  there  were  no  practical  difficulties  this  instru- 
ment would  be  admirable,  and  it  is  therefore  not  surprising  that  it 
should  have  met  Avith  so  much  favor  from  the  profession.     I  cannot 

^  Die  Transfusion  des  Bluies,  Leipzig,  1875. 


542  OBSTETRIC  OPERATIONS. 

but  think,  however,  that  the  operation  is  not  so  simple  as  at  fii'st  sight 
appears,  and  tliat  therefore  it  wants  one  of  the  essential  elements 
required  in  any  procedure  for  performing  transfusion.  One  of  my 
objeotions  is  that  it  is  by  no  means  easy  to  work  the  apparatus  without 
considerable  practice.  Of  this  I  have  satisfied  myself  by  asking  mem- 
bers of  my  class  to  work  it  after  reading  the  printed  directions,  and 
finding  that  they  are  not  always  able  to  do  so  at  once.  Of  course  it  may 
be  said  that  it  is  easy  to  acquire  the  necessary  manipulative  skill ;  but 
when  the  necessity  for  transfusion  arises  there  is  no  time  left  foi'  prac- 
tising with  the  instrument,  and  it  is  essential  that  an  apparatus  to  be 
universally  applicable  should  be  capable  of  being  used  immediately 
and  without  previous  experience.  Other  objections  are — the  necessity 
of  several  assistants,  the  uncertainty  of  there  being  a  sufficient  circula- 
tion of  blood"  m  the  veins  of  the  donor  to  afford  a  constant  supply,  and 
the  possibility  of  the  whole  apparatus  being  disturbed  by  restlessness  or 
jactitation  on  the  part  of  the  patient.  For  these  reasons  it  seems  to  me 
that  this  plan  of  immediate  transfusion  is  not  so  simple  nor  so  generally 
applicable  as  defibrination.  Still,  it  is  impossible  not  to  recognize  its 
merits,  and  it  is  certainly  well  worthy  of  further  study  and  investi- 
gation. 

Roussel's  Method. — Another  method  of  immediate  transfusion  is 
that  recommended  by  Roussel,^  whose  apparatus  has  recently  attracted 
considerable  attention.  It  possesses  many  undoubted  advantages,  and 
is  beyond  doubt  a  valuable  addition  to  our  means  of  performing  the 
operation.  It  has,  however,  the  great  disadvantage  of  being  costly  and 
complicated,  and  hence  I  do  not  believe  that  it  is  likely  to  come  into 
general  use. 

Schafer's  Method. — The  third  method  is  that  recommended  by  Dr. 
Schiifer  in  his  recent  excellent  reports  on  transfusion  submitted  to  the 
Obstetrical  Society.^  Schafer  suggests  two  methods  of  performing  the 
operation — one  from  vein  to  vein,  the  other  from  artery  to  artery.  The 
latter,  he  holds,  has  the  advantage  of  supplying  pure  oxygenated  blood 
under  the  best  possible  conditions  for  securing  the  amelioration  of  a 
patient  suffering  from  the  effects  of  profuse  hemorrhage.  The  neces- 
sary operative  proceedings  are,  however,  somewhat  complicated,  and  it 
seems  to  me  very  doubtful  if  this  plan  is  likely  to  be  at  all  commonly 
used.  His  method  of  immediate  transfusion,  however,  is  very  simple 
and  is  well  worthy  of  trial.  In  his  experiments  on  the  lower  animals 
it  answered  admirably.  I  am  not  aware  that  it  lias  yet  been  tried  on  the 
human  subject,  but  I  do  not  see  any  practical  difficulty  in  its  applica- 
tion. For  the  description  of  the  operation  I  have  inserted  Dr.  Schafer's 
own  directions  for  the  performance  of  both  arterial  and  venous  imme- 
diate transfusion. 

The  second  plan  for  obviating  the  bad  effects  of  clotting  is  the  addi- 
tion of  some  substance  to  the  blood  which  shall  prevent  coagulation. 
It  is  well  known  that  several  salts  have  this  property,  and  the  experi- 
ments made  in  the  case  of  cholera  patients  prove  that  solutions  of  some 
of  them  may  be  injected  into  the  venous  system  without  injury.     This 

^  Obstetrical  Transactions  for  1876,  vol.  xviii.  p.  280. 
^Ibid.,  for  1879,  vol.  xxi.  p.  316. 


THE  TRANSFUSION  OF  BLOOD.  543 

method  has  been  specially  advocated  by  Dr.  Braxton  Hicks,  who  uses 
a  solution  of  three  ounces  of  fresh  phosphate  j)f  soda  in  a  pint  of 
water,  about  six  ounces  of  which  are  added  to  the  quantity  of  blood 
to  be  injected.  He  has  narrated  4  cases ^  in  which  this  plan  was  adopted 
successfully,  so  far  as  the  prevention  of  coagulation  was  concerned.  It 
certainly  enables  the  operation  to  be  performed  with  deliberation  and 
care,  but  it  is  somewhat  complicated,  and  it  may  often  happen  that  the 
necessary  chemicals  are  not  at  hand.  A  further  objection  is  the  bulk 
of  fluid  which  . m list,  be  injected,  and  there  is  reason  to  believe  that  this 
has  in  some  cases  seriously  embarrassed  the  heart's  action  and  interfered 
with  the  success  of  tlie  operation.  In  many  of  the  successful  cases  of 
transfusion  the  amount  of  blood  injected  has  been  very  small,  not  more 
than  two  ounces.  Dr.  Richardson  proposes  to  prevent  coagulation  by 
the  addition  of  liquor  ammonise  to  the  blood  in  the  proportion  of  two 
minims  diluted  with  twenty  minims  of  water  to  each  ounce  of  blood. 
Defibrination  of  the  Blood. — The  last  method,  and  the  one  ^vhich, 
on  the  whole,  I  believe  to  be  the  simplest  and  most  eifectual,  is  defibrina- 
tion. It  has  been  chiefly  practised  in  Great  Britain  by  Dr.  McDonnell 
of  Dublin,  who  has  published  several  very  interesting  cases  in  which 
he  employed  it,  and  by  Martin  of  Berlin  and  De  Belina  of  Paris. 
The  process  of  removing  the  fibrin  is  simple  in  the  extreme,  and 
occupies  a  few  minutes  only.  Another  advantage  is  that  the  blood  to 
be  transfused  may  be  prepared  quietly  in  an  adjoining  apartment,  so 
that  the  operation  may  be  performed  with  the  greatest  calmness  and 
deliberation,  and  the  donor  is  spared  the  excitement  and  distress  which 
the  sight  of  the  apparently  moribund  patient  is  apt  to  cause,  and  which, 
as  Dr.  Hicks  has  truly  pointed  out,  may  interfere  with  the  free  flow  of 
blood.  The  researches  of  Pauum,  Brown-Sequard,  and  others  have 
proved  that  the  blood-corpuscles  are  the  true'  vivifying  element,  and 
that  defibrinated  blood  acts  as  well  in  every  respect  as  that  containing 
fibrin.  It  has  been  proved  that  the  fibrin  is  reproduced  within  a  short 
time,^  and  the  whole  tendency  of  modern  research  is  to  regard  it,  not  as 
an  essential  element  of  the  blood,  but  as  an  excrementitious  product 
resulting  from  the  degradation  of  tissue,  which  may  therefore  be  advan- 
tageously removed.  Another  advantage  derived  from  defibrination  is  • 
that  the  corpuscles  are  freely  exposed  to  the  atmosphere,  oxygen  is  taken  ( 
up,  and  carbonic  acid  given  ofl",  and  the  dangers  which  Brown-Sequard  i 
has  shown  to  arise  from  the  use  of  blood  containing  too  much  carbonic  \ 
acid  are  thereby  avoided.  There  can  be,  therefore,  no  physiological  'i 
objection  to  the  removal  of  the  fibrin,  which,  moreover,  takes  away  all 
practical  difliculty  from  the  operation.  The  straining  to  which  the 
defibrinated  blood  is  subjected  entirely  prevents  the  possibility  of  even 
the  most  minute  particle  of  fibrin  being  contained  in  the  injected  fluid ; 
the  risk  from  embolism  is  therefore  less  than  in  any  of  the  other  pro- 
cesses already  referred  to.  My  own  experience  of  this  plan  is  limited 
to  3  cases,  but  in  2  it  answered  so  well  that  I  can  conceive  no  reason- 
able objection  to  it.  I  should  be  inclined  to  say  that  transfusion, 
thus  performed,  is  amongst  the  simplest  of  surgical  operations — an 

'  Guy's  Hospital  Reports,  1869,  vol.  xiv.,  3d  series,  p.  1. 
''Panum,  Virehow's  Arch.,  vol.  xxvii. 


544  OBSTETRIC  OPERATIONS. 

opinion  whicli  the  experience  of  McDonnell  and  others  fully  con- 
firms. 

Transfusion  of  Milk. — Recently  the  intravenous  injection  of  freshly- 
cl4:aAvn  warm  milk  has  been  recommended  as  a  substitute  for  blood, 
chiefly  in  AmerTca,  It  was  first  used  by  Dr.  Hodder  of  Toronto,  but 
has  been  introduced  and  strongly  advocated  by  Thomas  of  New  York, 
who  has  used  it  twice  after  ovariotomy.  Brown-Scquard  in  experi- 
menting on  the  lower  animals  found  that  it  answered  as  well  as  either 
fresh  or  defibrinated  blood,  and  about  half  an  hour  after  the  injection 
no  trace  of  the  milk-corpuscles  could  be  found  in  the  blood.  Schiifer, 
however,  found  that  the  action  of  milk  on  the  blood-corpuscles  was 
highly  deleterious,  and  that  it  introduces  the  germs  of  septic  organisms 
likely  to  produce  very  serious  results.  He  therefore  pronounces  strongly 
against  its  use. 

Statistical  Results. — The  number  of  cases  of  transfusion  are  per- 
haps not  sufficient  to  admit  of  completely  reliable  conclusions.  It  is 
certain,  however,  that  transfusion  has  often  been  the  means  of  rescuing 
the  patient  when  apparently  at  the  point  of  death  after  all  other  means 
of  treatment  had  failed.  Professor  Martin  records  57  cases,  in  43  of 
which  transfusion  was  completely  successful,  and  in  7  temporarily  so, 
while  in  the  remaining  7  no  reaction  took  place.  Dr.  Higginson  of 
Liverpool  has  had  15  cases,  10  of  which  were  successful.  Figures  such 
(as  these  are  encouraging,  and  they  are  sufficient  to  prove  that  the  opera- 
Ition  is  one  which  at  least  offers  a  fair  hojDC  of  success,  and  which  no 
iobstetrician  would  be  justified  in  neglecting  when  the  patient  is  sinking 
'from  the  exhaustion  of  profuse  hemorrhage.  It  is  to  be  hoped  also 
that  further  experience  may  prove  it  to  be  of  value  in  other  cases  in 
which  its  use  has  been  suggested,  but  not,  as  yet,  put  to  the  test  of 
exjDeriment. 

Possible  Dangers  of  the  Operation. — The  possible  risks  of  the 
operation  would  seem  to  be  the  danger  of  injecting  minute  particles  of 
fibrin,  which  form  emboli,  of  bubbles  of  air,  or  of  overwhelming  the 
action  of  the  heart  by  injecting  too  rapidly  or  in  too  great  cj^uantity. 
These  may  be,  to  a  great  extent,  prevented  by  careful  attenfion  to  the 
proper  performance  of  the  operation,  and  it  does  not  clearly  appear, 
from  tlie  recorded  cases,  that  they  have  ever  proved  fatal.  AVe  must 
also  bear  in  mind  that  transfusion  is  seldom  or  never  likely  to  l)e 
attempted  until  the  patient  is  in  a  state  which  would  otherwise  almost 
certainly  preclude  the  hope  of  recovery,  and  in  whicli,  therefore,  much 
more  hazardous  proceedings  would  hp  fully  justified. 

Cases  Suitable  for  Transfusion.-vThe  cases  suitable  for  transfusion 
are  those  in  which  the  patient  is  reduced  to  an  extreme  state  of  exhaus- 
tion from  hemorrhage  during  or  after  labor  or  miscarriage,  whether  by 
the  repeated  losses  of  placenta  prsevia  or  the  more  sudden  and  profuse 
flooding  of  post-partum  hemorrhage.)  The  operation  Avill  not  be  con- 
templated until  other  and  simpler  means  have  been  tried  and  failed,  or 
until  the  symptoms  indicate  that  life  is  on  the  verge  of  extinction.  If 
the  patient  should  be  deadly  pale  and  cold,  with  no  pulse  at  the  Avrist 
or  one  that  is  scarcely  perceptible ;  if  she  be  unable  to  swallow  or  vomits 
incessantly ;  if  she  lie  in  an  unconscious  state ;  if  jactitation  or  convul- 


THE  TRANSFUSION  OF  BLOOD. 


545 


sions  or  repeated  faiDtings  should  occur ;  if  the  respiration  be  laborious 
or  very  rapid  and  sighing  •  if  the  pupil  do  not  act  under  the  influence 
of  light, — it  is  evident  that  she  is  in  a  condition  of  extreme  danger, 
and  it  is  under  such  circumstances  that  transfusion,  performed  suflfici- 
ently  soon,  offers  a  fair  prospect  of  success.  It  does  not  necessarily 
follow  because  one  or  other  of  these  symptoms  is  present  that  there  is  no 
chance  of  recovery  under  ordinary  treatment,  and  indeed,  it  is  within 
the  experience  of  all  that  patients  have  rallied  under  apparently  the 
most  hopeless  conditions.  But  when  several  of  them  occur  together 
the  prospect  of  recovery  is  much  diminished,  and  transfusion  would 
then  be  fully  justified,  especially  as  there  is  no  reason  to  think  that  a 
fatal  result  has  ever  been  directly  traced  to  its  employment.  Indeed, 
like  most  other  obstetric  operations,  it  is  more  likely  to  be  postponed 
until  too  late  to  be  of  good  service  than  to  be  employed  too  early  ;  and 
in  some  of  the  cases  reported  as  unsuccessful  it  was  not  performed  until 
respiration  had  ceased  and  death  had  actually  taken  place.  It  has  some- 
times been  said  that  transfusion  should  never  be  employed  if  the  uterus 
be  not  firmly  contracted,  so  as  to  prevent  the  injected  blood  again  escap- 
ing through  the  uterine  sinuses.  The  cases  in  which  this  is  likely  to 
occur  are  few ;  and  if  one  were  met  with  the  escape  of  blood  could  be 
prevented  by  the  injection  into  the  uterus  of  the  perchloride  of  iron. 

Description  of  the  Operation. — In  describing  the  operation  I  shall 
limit  myself  to  an  account  of  Aveling's  and  Schafer's  method  of  imme- 
diate transfusion,  and  to  that  of  injecting  defibrinated  blood.  I  con- 
sider myself  justified  in  omitting  any  account  of  the  numerous  instru- 
ments which  have  been  invented  for  the  purpose  of  injecting  pure  blood, 
since  I  believe  the  practical  difficulties  are  too  great  ever  to  render  this 
form  of  operation  serviceable.  The  great  objection  to  most  of  them  is 
their  cost  and  complexity ;  and  as  long  as  any  special  apparatus  is  con- 
sidered essential,  the  full  benefits  to  be  derived  from  transfusion  are  not 


Fig.  194. 


Method  of  Transfusion  by  Aveling's  Apparatus. 


likely  to  be  realized.    The  necessity  for  employing  it  arises  suddenly ;  it 
may  be  in  a  locality  in  which  it  is  impossible  to  procure  a  special  iustru- 


35 


546  OBSTETRIC  OPERATIONS. 

ment ;  and  it  would  be  well  if  it  were  understood  that  transfusion  may- 
be safely  and  effectually  performed  by  the  simplest  means.  In  many 
of  the  successful  cases  an  ordinary  syringe  was  used ;  in  one,  in  the 
absence  of  other  instruments,  a  child's  toy  syringe  was  emjjloyed.  I 
have  myself  performed  it  with  a  simple  syringe  purchased  at  the  nearest 
chemist's  shop  when  a  special  transfusion  apparatus  failed  to  act  satis- 
factorily. 

In  immediate  transfusion  (Fig.  194)  the  donor  is  seated  close  to  the 
patient,  and,  the  veins  in  the  arms  of  each  having  been  opened,  the 
silver  cauula  at  either  end  of  the  instrument  is  introduced  into  them 
(a  b).  The  tube  between  the  bulb  and  the  donor  is  now  pinched  (d), 
so  as  to  form  a  vacuum,  and  the  bulb  becomes  filled  with  blood  from 
the  donor.  The  finger  is  now  removed  so  as  to  compress  tlie  distal  tube 
(d'),  and,  the  bulb  being  compressed  (c),  its  contents  are  injected  into 
the  patient's  vein.  The  bulb  is  calculated  to  hold  about  two  drachms, 
so  that  the  amount  injected  can  be  estimated  by  the  number  of  times  it 
is  emj3tied.  The  risk  of  injecting  air  is  prevented  by  filling  the  syringe 
with  water,  which  is  injected  before  the  blood. 

Schafer's  Directions  for  Immediate  Transfusion. 

Direct  Venous  Transfusion. — "■  Procure  two  glass  canulas  of  appro- 
priate size  and  shape  (see  Fig.  195),  and  a  piece  of  black  india-rubber 
tubing  seven  inches  long,  and  not  less  than  a  quarter  of  an  inch  bore, 
fitted  to  the  canulas.     This  apj)aratus  could  always  be 
Fig.  195.         improvised. 

"Place  the  transfusion-tube  in  a  basin  of  hot  water 
containing  a  little  carbonate  of  soda.  Put  a  tape 
round  the  arm  of  the  patient  just  below  the  place 
where  the  vein  is  to  be  opened,  and  another  just  above. 
Expose  the  vein  by  an  incision  through  the  skin,  which 
should  be  made  transversely  if  the  position  of  the  vein 
cannot  be  made  out  tlirough  the  skin.  Clear  a  small 
piece  of  the  vein  with  forceps  and  slip  a  pointed  piece 
of  card  underneath  it.  By  a  snip  with  scissors  make  an 
oblique  opening  into  the  vein,  and  partly  insert  a  small 
blunt  instrument  (such  as  a  wool-needle),  so  that  the 
aperture  is  not  lost.  Remove  the  upper  tape.  Next 
prepare  the  vein  of  the  giver.  To  do  this  put  tapes 
around  the  arm  just  below  and  above  the  place  where  the  vein  is  to 
be  opened.  Expose  the  vein  by  a  longitudinal  incision  through  the 
skin.  Clear  a  small  piece  of  the  vessel  with  forceps  and  pass  a  thread 
ligature  underneath.  A  slip  of  card  may  also  be  placed  under  this  vein. 
Make  a  snip  into  the  vein  just  above  the  ligature,  and  then,  taking  the 
transfusion-tube  out  of  the  soda  solution,  slip  one  of  the  canulas  into 
the  vein  of  the  giver  and  tie  it  in  with  a  simple  knot,  which  can  be 
readily  untied.  Let  the  giver  go  to  the  bedside  and  place  his  arm 
alongside  that  of  the  patient.  Hold  the  end  of  the  india-rubber  tube 
with  the  second  canula  up  a  little,  and  release  the  lower  tape  on  the  arm 
of  the  blood-ffiver.     As  soon  as  the  blood  flows  out  of  the  second 


THE  TRANSFUSION  OF  BLOOD.  547 

canula  pinch  the  india-rubber  tube  close  to  the  canula,  so  as  to  stop  the 
flow,  and,  removing  the  wool-needle,  slip  the  end  of  the  canula  into  the 
vein  of  the  patient ;  hold  it  there,  and  allow  the  blood  to  pass  freely 
along  the  tube.  Three  minutes  will  generally  be  long  enough  for  the 
flow,  which  can  be  stopped  by  compressing  the  vein  of  the  giver  below 
the  canula.  Both  canulas  may  now  be  withdrawn  and  the  ligature 
removed  from  the  vein  of  the  giver,  the  cut  veins  being  dealt  with  in 
the  usual  way.  Of  course,  the  other  tape  on  the  arm  of  the  donor  must 
be  removed  as  soon  as  the  transfusion  is  over. 

"  Instead  of  using  the  transfusion-tube  empty,  it  may  be  filled  with 
soda  solution,  to  the  exclusion  of  air.  It  is  necessary  to  have  one  or 
two  spring  clips  on  the  tube  to  prevent  the  escape  of  the  solution.  This 
is  a  much  better  plan  than  the  other,  for  the  blood  need  not  be  allowed 
to  flow  into  the  tube  until  the  second  canula  is  inserted,  and  then  by 
opening  the  clips  it  may  drive  the  soda  solution  before  it  into  the  vein. 
The  small  quantity  of  carbonate-of-soda  solution  necessary  to  fill  the 
simj)le  tube  will  do  the  patient  no  harm. 

"  In  the  first  place,  we  have  to  determine  what  artery  or  arteries 
would  be  most  available  for  the  purpose.  The  (left)  radial  artery  could 
be  most  easily  dealt  with,  and  its  use  would  involve  less  subsequent 
inconvenience  to  the  donor  of  the  blood  than  any  other.  But  if  it  is 
considered  necessary  to  choose  some  other  artery,  I  think  the  dorsal 
artery  of  the  foot  should  be  selected,  for  its  employment  presents  sev- 
eral advantages.  It  is  a  minor  artery,  but  nevertheless  large  enough 
for  the  insertion  of  a  canula ;  it  is  comparatively  superficial  and  pretty 
easily  found  ;  and  by  causing  the  person  yielding  the  blood  to  stand  up 
a  great  amount  of  pressure  may  be  obtained  in  it.  In  the  bloodless 
patient,  especially  if  there  be  much  subcutaneous  fat,  this  artery  might 
not  be  readily  found. 

Apparatus  Required. — "A  piece  of  india-rubber  tubing  six  or 
seven  inches  long,  two  glass  canulas  of  appropriate  size  and  shape,  and 
some  spring  clips,  two  of  M^hich  should  be  small  for  compressing  the 
arteries,  the  others  larger  and  adapted  for  clipping  the  tube.  The 
smaller  clips  might  be  dispensed  with,  and  ligatures  fastened  with  a 
slip  bow  might  be  used  instead,  in  the  way  Lower  recommended.  Be- 
fore commencing  it  is  important  to  ensure  that  the  india-rubber  tube 
cannot  slip  off  the  canulas.  It  ought  to  be  secured  to  them  by  tight 
ligatures  or  by  binding  wire.  This  precaution  is  necessary  because  the 
arterial  blood  is  under  considerable  pressure.  This  would  tend  to  force 
the  tubes  apart  and  might  cause  copious  hemorrhage. 

"  The  transfusion-tube  is  to  be  placed  as  before  in  carbonate-of-soda 
solution. 

Procedure. — "The  artery  of  the  patient  must  first  be  exposed.  To 
do  this  make  an  incision  an  inch  in  length  through  the  skin  over  the 
line  of  the  artery,  and  then  divide  to  an  equal  extent  the  subcutaneous 
tissue  and  fascia  which  cover  it.  About  three-quarters  of  an  inch  in 
length  of  the  vessel  is  to  be  separated  from  the  ensheathing  connective 
tissue  and  from  its  accompanying  veins  by  slipping  a  blunt  instrument, 
such  as  an  aneurism-needle  or  the  blade  of  a  forceps,  underneath  and 
moving  it  up  and  down.     A  small  piece  of  card,  cut  into  a  long  trian- 


548  OBSTETRIC  OPERATIONS. 

gular  shape,  may  then  be  placed  under  instead  of  the  needle.  A  liga- 
ture is  then  tied  tightly  around  the  lower  end  of  the  piece  of  artery, 
another  is  looped  loosely  around  the  middle,  and  a  spring  clip  is  put  on 
close  to  the  upper  end.  The  vessel  may  now  be  opened  just  above  the 
lower  ligature  by  a  snip  with  the  scissors. 

"If  the  artery  have  any  branch  at  the  exposed  part,  this  ought  to  be 
tied  before  commencing  to  isolate  the  vessel.  In  the  person  who  is  to 
yield  the  blood  exactly  the  same  process  is  carried  out. 

"The  transfusion-tube  is  next  filled  (by  suction)  with  soda  solution, 
and  this  is  prevented  from  escaping  by  one  or  two  spring  clips  on  the 
tube. 

"  One  of  the  glass  terminals  is  tied  into  the  artery  of  the  giver,  and 
the  other  into  the  artery  of  the  patient,  the  ends  of  both  being  directed 
toward  the  heart, 

"All  is  now  ready  for  the  transfusion.  To  effect  this,  remove  the 
clips  on  the  india-rubber  tube  and  open  the  clip  on  the  artery  of  the 
patient ;  then  open — not  remove — that  on  the  artery  of  the  giver,  and 
keep  it  open  onejminute,  or  a  little  longer  if  it  seems  advisable.  Allow 
the  clips  to  close  again,  and  if  the  patient's  condition  is  ameliorated  the 
operation  may  be  ended  by  tying  the  arteries — first  that  of  the  giver, 
then  that  of  the  patient — -just  above  the  clips. 

"  Finally,  cut  out  and  remove  the  canulas,  together  with  the  pieces  of 
artery  into  which  they  are  tied." 

Injection  of  Defibrinated  Blood. — For  injecting  defibrinated  blood 
various  contrivances  have  been  used.  ("McDonnell's  instrument  is  a 
simple  cylinder  with  a  nozzle  attached,  from  which  the  blood  is  pro- 
pelled by  gravitation.'  When  the  propulsive  power  is  insufficient, 
increased  pressure  is  applied  by  breathing  forcibly  into  the  open  end  of 
the  receiver.  De  Belina's  instrument  is  on  the  same  principle,  only 
atmospheric  pressure  is  supplied  by  a  contrivance  similar  to  Richard- 
son's spray-producer  attached  to  one  end.  The  idea  is  simjjle,  but  there 
is  some  doubt  of  a  gravitation  instrument  being  sufficiently  powerful, 
and  it  certainly  failed  in  my  hands.  '  I  have  had  valves  applied  to 
Aveling's  instrument,  so  that  it  works  by  compression  of  the  bulb,  like 
an  ordinary  Higginson's  syringe. '  This,  with  a  single  silver  canula  at 
one  end  for  introduction  into  the  vein,  forms  a  perfect  and  inexpensive 
transfusion  apparatus,  taking  up  scarcely  any  space.  If  it  be  not  at 
hand,  any  small    syringe  with  a   tolerably  fine  nozzle  may  be   used. 

The  first  step  of  the  operation  is  defibrination  of  the  blood,  M'hich 
should,  if  possible,  be  prepared  in  an  apartment  adjoining  the  patient's. 
The  blood  should  be  taken  from  the  arm  of  a  strong  and  healthy  man. 
The  quality  cannot  be  unimportant,  and  in  some  recorded  cases  the  fail- 
ure of  the  operation  has  been  attributed  to  the  fact  of  the  donor  having 
been  a  weakly  female.  The  supply  from  a  woman  might  also  prove 
insufficient ;  and  although  it  has  been  shown  that  blood  from  two  or 
more  persons  may  be  used  with  safety,  yet  such  a  change  necessarily 
causes  delay,  and  should,  if  possible,  be  avoided.  A  vein  having  been 
opened,  eight  or  ten  ounces  of  blood  are  withdrawn  and  received  into 
some  perfectly  clean  vessel,  such  as  a  dessert  finger-glass.  As  it  flows 
it  should  be  briskly  agitated  with  a  clean  silver  fork  or  a  glass  rod,  and 


THE  TRANSFUSION  OF  BLOOD.  549 

very  shortly  strings  of  fibrin  begin  to  form.  It  is  now  strained  through 
a  piece  of  fine  muslin,  previously  dipped  in  hot  water,  into  a  second 
vessel  which  is  floating  in  water  at  a  temperature  of  about  105°.  By 
this  straining  the  fibrin  and  all  air-bubbles  resulting  from  the  agitation 
are  removed,  and  if  there  be  no  excessive  hurry  it  might  be  well  to 
repeat  the  straining  a  second  time.  If  the  vessel  be  kept  floating  in 
warm  water,  the  blood  is  prevented  from  getting  cool,  and  we  can  now 
proceed  to  prepare  the  arm  of  the  patient  for  injection. 

This  is  the  most  delicate  and  difficult  part  of  the  operation,  since  the 
veins  are  generally  collapsed  and  empty,  and  by  no  means  easy  to  find. 
The  best  way  of  exposing  them  is  that  practised  by  McDonnell,  who 
pinches  up  a  fold  of  the  skin  at  the  bend  of  the  elbow  and  transfixes 
it  with  a  fine  tenotomy-knife  or  scalpel,  so  making  a  gaping  wound  in 
the  integument,  at  the  bottom  of  which  they  are  seen  lying.  A  probe 
should  now  be  passed  underneath  the  vein  selected  for  opening,  so  as  to 
avoid  the  chance  of  its  being  lost  at  any  subsequent  stage  of  the  opera- 
tion. This  is  a  point  of  some  importance,  and  from  the  neglect  of  this 
precaution  I  have  been  obliged  to  open  another  vein  than  that  origi- 
nally fixed  on.  A  small  portion  of  the  vein  being  raised  with  the  for- 
ceps, a  nick  is  made  into  it  for  the  passage  of  the  canula. 

Injection  of  the  Blood. — The  prepared  blood  is  now  brought  to  the 
bedside,  and,  the  apparatus  having  been  previously  filled  with  blood  to 
avoid  the  risk  of  injecting  any  bubbles  of  air,  the  canula  is  inserted 
into  the  opening  made  in  the  vein  and  transfusion  commenced.  It 
should  be  constantly  borne  in  mind  that  this  part  of  the  operation 
should  be  conducted  with  the  greatest  caution,  the  blood  introduced 
very  slowly,  and  the  effect  on  the  patient  carefully  watched.  The  injec- 
tion"hiay  be  proceeded  with  until  some  perceptible  effect  is  produced, 
which  will  generally  be  a  return  of  the  pulsation,  first  at  the  heart  and 
subsequently  at  the  wrist,  an  increase  in  the  temperature  of  the  body, 
greater  depth  and  frequency  of  the  respirations,  and  a  general  appear- 
ance of  returning  animation  about  the  countenance.  Sometimes  the 
arms  have  been  thrown  about  or  spasmodic  twitchings  of  the  face  have 
taken  place.  The  quantity  of  blood  required  to  produce  these  effects 
varies  greatly,  but  in  the  majority  of  cases  has  been  very  small.  Occa- 
sionally 2  ounces  have  proved  sufficient,  and  the  average  may  be  taken 
as  rangino;  between  4  and  6,  althoua;h  in  a  few  cases  between  10  and  20 
have  been  used.  The  practical  rule  is  to  proceed  very  slowly  with  the 
injection  until  some  perceptible  result  is  observed.  Should  embarrassed, 
or  frequent  respiration  supervene,  we  may  suspect  that  we  have  been 
injecting  either  too  great  a  quantity  of  blood  or  with  too  much  force 
and  rapidity,  and  the  operation  should  at  once  be  suspended,  and  not 
resumed  until  the  suspicious  symptoms  have  passed  away.  It  may  hap- 
pen that  the  effects  of  the  transfusion  have  been  highly  satisfactory,  but 
that  in  the  course  of  time  there  is  evidence  of  returning  syncope.  This 
may  possibly  be  prevented  by  the  administration  of  stimulants;  but  if 
these  fail  there  is  no  reason  why  a  fresh  supply  of  blood  should  not 
again  be  injected,  but  this  should  be  done  before  the  effects  of  the  first 
transfusion  have  entirely  passed  away. 

Secondary  Effects  of  Transfusion. — The   subsequent   effects  iu 


550  OBSTETRIC  OPERATIONS. 

successful  cases  of  transfusion  merit  careful  study.  In  some  few  cases 
death  is  said  to  have  happened  within  a  few  weeks,  with  symptoms 
resembling  pytemia.  Too  little  is  known  on  this  point,  however,  to 
justify  any  positive  conclusions  witli  regard  to  it. 

[Transfusion  with  defibrinated  blood  was,  I  believe,  first  tried  in 
America  by  Dr.  Joshua  G.  Allen  of  Philadelphia  on  December  30, 
1868,  on  a  woman  who  suffered  from  the  effects  of  repeated  attacks  of 
uterine  hemorrhage.  Six  fluidouuces  were  injected,  and  the  patient 
recovered  a  reasonable  degree  of  health.  In  1869,  Dr.  Allen  repeated 
the  operation  4  times,  in  2  of  the  cases  being  associated  with  Dr. 
Thomas  G.  Morton  at  the  Pennsylvania  Hospital,  and  using  a  double 
vessel  for  keeping  the  blood  warm,  consisting  of  a  conical  cup  for  hold- 
ing the  blood  and  a  lower  vessel  for  containing  warm  water,  the  two 
being  made  in  one  and  the  temperature  ascertained  by  an  outside  ther- 
mometer. Dr.  Morton  repeated  the  experiment  on  two  other  patients 
in  1870  and  1874,  the  second,  a  girl  of  eleven,  being  operated  on  twice, 
at  intervals  of  six  weeks,  for  bleeding  from  the  nose  and  bladder,  the 
effect  of  purpura :  she  entirely  recovered.  Dr.  ]M.  used  a  set  of  instru- 
ments specially  designed  for  the  work,  and  shown  in  illustration  in  the 
American  Journal  of  the  Medical  Sciences,  July,  1874,  p.  112.  Between 
1874  and  1886  he  repeated  the  operation  on  several  hospital  and  private 
patients.  \ 

Intravenous  saline  injections  are  far  more  readily  used,  are  safer,  1 
and  are  believed  from  the  tests  that  have  been  made  to  be  quite  as  effi-  1 
cacious  as  blood.  What  has  bfeen  called  artificial  serum  consists  of  20  ! 
grammes  of  sulphate  of  soda  and  10  grammes  of  chloride  of  sodium  in  2  | 
litres  of  water.  The  solution  should  be  injected  into  a  large  vein  slowly  I 
and  in  large  quantity,  as  much  as  a  pint  or  more  at  a  time,  and  repeated  | 
at  intervals  :  the  fluid  should  be  blood-warm.  Another  formula  consists  I 
of  pure  common  salt  1|^  fluiddrachms,  liquor  potassse  1  minim,  and/ 
pui'e  carbonate  of  potash  45  grains  in  two  quarts  of  water. — Ed.]         / 


PART  V. 

THE  PUERPERAL  STATE. 


CHAPTER   I. 

THE  PUERPEEAL  STATE  AND  ITS  MANAGEMENT. 

Importance  of  Studying-  the  Puerperal  State. — The  key  to  the 
management  of  women  after  labor,  and  to  the  proper  nnderstanding  of 
the  many  important  diseases  which  may  then  occur,  is  to  be  found  in  a 
study  of  the  phenomena  following  delivery  and  of  the  changes  going 
on  in  the  mother's  system  during  the  puerperal  period.  No  doubt  nat- 
ural labor  is  a  physiological  and  healthy  function,  and  during  recovery 
from  its  effects  disease  should  not  occur.  It  must  not  be  forgotten, 
however,  that  none  of  our  patients  are  under  physiologically  healthy 
conditions.  The  surroundings  of  the  lying-in  woman,  the  effects  of 
civilization,  of  errors  of  diet,  of  defective  cleanliness,  of  exposure  to 
contagion,  and  of  a  hundred  other  conditions  which  it  is  impossible  to 
appreciate,  have  most  important  influences  on  the  results  of  childbirth. 
Hence  it  follows  that  labor,  even  under  the  most  favorable  conditions, 
is  attended  with  considerable  risk. 

The  Mortality  of  Childbirth, — It  is  not  easy  to  say  with  accuracy 
what  is  the  })recise  mortality  accompanying  childbirth  in  ordinary 
domestic  practice,  since  the  returns  derived  from  the  reports  of  the 
Registrar-General  or  from  private  sources  are  manifestly  open  to  serious 
error.  The  nearest  approach  to  a  reliable  estimate  is  that  made  by  Dr. 
Matthews  Duncan,^  who  calculates,  from  figures  derived  from  various 
sources,;  that  no  fewer  than  1  out  of  every  120  women,  delivered  at  or 
near  the  full  time,  dies  within  four  weeks  of  childbirth.]  This  indicates 
a  mortality  far  above  that  which  has  been  generally  believed  to  accom- 
pany childbearing  under  favorable  circumstances.  It,  however,  closely 
approximates  to  a  similar  estimate  made  by  McClintock,^  who  calculates 
the  mortality  in  England  and  Wales  as  1  in  126,  and  in  the  upper  and 
middle  classes  alone,  where  the  conditions  may  naturally  be  supposed 
to  be  more  favorable,  at  1  in  146;  more  recently  he  has  come  to  the 
conclusion,  from  his  own  increased  experience  and  the  published  results 
of  the  practice  of  others,  that  1  in  100  would  more  correctly  represent 
the  rate  of  puerperal  mortality.^     In  these  calculations  there  are  some 

^  The  "Mortality  of  Childbed,"  Edin.  Med.  Journ.,  vol.  1869-70,  p.  399. 
^  Dublin  Quarterly  Journ..  of  Med.  Science,  1869,  vol.  xlviii.  p.  256. 
=*  Brit.  Med.  Journ.,  1878,  vol.  ii.  p.  215. 

551 


552  THE  PUERPERAL  STATE. 

obvious  sources  of  error,  since  they  include  deatlis  from  all  causes 
Avitliiu  four  weeks  of  delivery,  some  of  which  must  have  been  inde- 
pendent of  the  puerperal  state. 

But  it  is  not  the  deaths  alone  which  should  be  considered.  All  prac- 
titioners know  how  large  a  number  of  their  patients  suffer  from  morbid 
states  M'hich  may  be  directly  traced  to  the  effects  of  childbearing.  It 
is  impossible  to  arrive  at  any  statistical  conclusion  on  this  point,  but  it 
must  have  a  very  sensible  and  important  influence  on  the  health  of 
childbearing  women. 

Alterations  in  the  Blood  after  Delivery. — The  state  of  the  blood 
during  pregnancy,  already  referred  to  (p.  143),  has  an  important  bear- 
ing on  the  puerperal  state.  There  is  hyperinosis,  which  is  largely 
increased  by  the  changes  going  on  immediately  after  the  birth  of  the 
child,  for  then  the  large  supply  of  blood  which  has  been  going  to  the 
uterus  is  suddenly  stopped,  and  the  system  must  also  get  rid  of  a  quan- 
tity of  effete  matter  thrown  into  the  circulation  in  consequence  of  the 
degenerative  changes  occurring  in  the  muscular  fibres  of  the  uterus. 
Hence  all  the  depurative  channels  by  which  this  can  be  eliminated  are 
called  on  to  act  with  great  energy.  If,  in  addition,  the  peculiar  condi- 
tion of  the  generative  tract  be  borne  in  mind — viz.  the  large  open  ves- 
sels on  its  inner  surface,  the  partially  bared  inner  surface  of  the  uterus, 
and  the  channels  for  absorption  existing  in  consequence  of  slight  lacera- 
tions in  the  cervix  or  vagina — it  is  not  a  matter  of  surprise  that  septic 
diseases  should  be  so  common. 

It  will  be  well  to  consider  successively  the  various  changes  going  on 
after  delivery,  and  then  we  shall  be  in  a  better  position  for  studying 
the  rational  management  of  the  puerperal  state. 

Some  degree  of  nervous_  shock  or  exhaustion  is  observable  after 
most  labors.  In  many  cases  it  is  entirely  absent ;  in  others  it  is  well 
marked.  Its  amount  is  in  proportion  to  the  severity  of  the  labor  and 
the  susceptibility  of  the  patient ;  and  it  is  therefore  most  likely  to  be 
excessive  in  women  who  have  suffered  greatly  from  pain,  who  have 
undergone  much  muscular  exertion,  or  who  have  been  weakened  from 
undue  loss  of  blood.  It  is  evidenced  by  a  feeling  of  exhaustion  and 
fatigue,  and  not  uncommonly  there  is  some  shivering,  which  soon  passes 
off,  and  is  generally  followed  by  refreshing  sleep.  The  extreme  nervous 
susceptibility  continues  for  a  considerable  time  after  delivery,  and 
indicates  the  necessity  of  keeping  the  lying-in  patient  as  free  from  all 
sources  of  excitement  as  possible. 

Immediately  after  delivery  the  puke^falls,  and  the  importance  of  this 
as  indicating  a  favorable  state  of  tlie  ])atient  has  already  been  alluded 
to.  The  condition  of  the  pulse  has  been  carefidly  studied  by  Blot,' 
who  has  shown  that  this  diminution,  which  he  believes  to  be  connected 
with  a  diminished  tension  in  the  arteries  due  to  tlie  sudden  arrest  of 
the  uterine  circulation,  continues  in  a  large  proportion  of  cases  for  a 
considerable  number  of  days  after  delivery  ;  and  as  a  matter  of  clinical 
import  as  long  as  it  does  the  patient  may  be  considered  to  be  in  a  favor- 
able state.  In  many  instances  the  slowness  of  the  pulse  is  remarkable, 
often  sinking  to  50,  or  even  40^  beats  per  minute.  /  Any  increase  abov^e 

1  Arch,  gen  de  Med.,  1864. 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.          553 

the  normal  rate,  es2:>ecially  if  at  all  continuous,  should  always  be  care- 
fully noted  and  looked  on  with  suspicion."^  In  connection  with  this  sub- 
ject, however,  it  must  be  remembered  that  in  puerperal  women  the  most 
trivial  circumstances  may  cause  a  sudden  rise  of  the  pulse.  This  must 
be  familiar  to  every  practical  obstetrician,  who  has  constant  opportuni- 
ties of  observing  this  effect  after  any  transient  excitement  or  fatigue. 
In  lying-in  hospitals  it  has  generally  been  observed  that  the  occurrence 
of  any  particularly  bad  case  will  send  up  the  pulse  of  all  the  other 
patients  who  may  have  heard  of  it. 

The  temperature  in  the  lying'-in  state  affords  much  valuable 
information.  During  and  for  a  short  time  after  labor  there  is  a  slight 
elevation.  It  soon  falls  to,  or  even  somewhat  below,  the  normal  level. 
Squire  found  that  the  fall  occurred  within  twenty-four  hours,  sometimes 
within  twelve  hours,  after  the  termination  of  labor.  ^  For  a  few  days 
there  is  often  a  slight  increase  of  temperature,  especially  toward  the 
evening,  which  is  probably  caused  by  the  rapid  oxidation  of  tissue  in 
connection  with  the  involution  of  the  uterus.  In  about  forty-eight 
hours  there  is  a  rise  connected  with  the  establishment  of  lactation 
amounting  to  one  or  two  degrees  over  the  normal  level,  but  this  again 
subsides  as  soon  "as  the  milk  is  freely  secreted.  Crede  has  also  shown  ^ 
that  rapid  but  transient  rises  of  temperature  may  occur  at  any  period, 
connected  with  trivial  causes,  such  as  constipation,  errors  of  diet,  or 
mental  disturbances.  But  if  there  be  any  rise  of  temperature  whicli\ 
is  at  all  continuous,  especially  to  over  100°  Fahr.,  and  associated  with . 
rapidity  of  the  pulse,  there  is  reason  to  fear  the  existence  of  some  com- 
plication. 

The  Secretions  and  Excretions. — The  various  secretions  and  excre- 
tions are  carried  on  with  increased  activity  after  labor.  The  skin 
especially  acts  freely,  the  patient  often  sweating  profusely.  There  is 
also  an  abundant  secretion  of  urine,  but  not  uncommonly  a  difficulty 
of  voiding  it,  either  on  account  of  temporary  paralysis  of  the  neck  of 
the  bladder,  resulting  from  the  pressure  to  which  it  has  been  subjected, 
or  from  swelling  and  occlusion  of  the  urethra.  For  the  same  reason 
the  rectum  is  sluggish  for  a  time,  and  constipation  is  not  infrequent. 
The  a^etite  is  generally  indifferent,  and  the  patient  is  often  thirsty. 
('Generally  in  about  forty-eight  hours  the  secretion  of  milk  becomes 
established,  and  this  is  occasionally  accompanied  by  a  certain  amount 
of  constitutional  irritation.]  The  breasts  often  become  turgid,  hot,  and 
painful.  There  may  or  may  not  be  some  general  disturbance,  quicken- 
ing of  pulse,  elevation  of  temperature,  possibly  slight  shivering,  and  a 
general  sense  of  oppression,  which  are  quickly  relieved  as  the  milk  is 
formed  and  the  breasts  emptied  by  suckling.  Squire  says  that  the 
most  constant  phenomenon  connected  with  the  temperature  is  a  slight 
elevation  as  the  milk  is  secreted,  rapidly  falling  when  lactation  is 
established.  Barker  noted  elevation  either  of  temperature  or  pulse 
in  only  4  out  of  52  cases  which  were  carefully  watched.  There  can 
be  little  doubt  that  the  importance  of  the  so-called  "  milk  fever  "  has 
been  immensely  exaggerated,  and  its  existence  as  a  normal  accompani- 

^  "  Puerperal  Temperature,"  Obstetrical  Transactions,  1868,  vol.  ix.  p.  129. 
'^Monat.f.  Gebiirt.,  1868,  Bd.  xxxii.  S.  453. 


554  THE  PUERPERAL  STATE. 

ment  of  the  puerperal  state  is  more  than  doubtful.  It  is  certaiu,  how- 
ever, that  in  a  small  minority  of  cases  there  is  an  appreciable  amount 
of  distur])ance  about  the  time  that  the  milk  is  formed.  Out  <jf  423 
cases,  Macau'  found  that  in  113,  or  about  27  per  cent.,  there  Avas  no 
rise  of  temperature;  in  226  the  temperature  did  rise  to  100°  and  over, 
and  of  these  in  32,  or  a  little  over  7  per  cent.,  the  only  ascertainable 
cause  "Was  a  painful  or  distended  condition  of  the  breast.  Many 
modern  Avriters,  such  as  AVinckel,  Griinewaldt,  and  D'Espine,  entirely 
deny  the  connection  of  this  disturbance  with  lactation,  and  refer  it  to 
a  slight  and  transient  septicaemia.  Graily  Hewitt  remarks  that  it  is 
most  commonly  met  Avith  when  the  patient  is  kept  low  and  on  deficient 
diet  after  delivery,  especially  Mhen  the  system  is  below  par  from  hemor- 
rhage or  any  other  cause.  This  observation  will  no  doubt  account  for 
the  comparative  rarity  of  febrile  disturbance  in  connection  with  lactation 
in  these  days,  in  M-hich  the  starving  of  puerperal  patients  is  not  con- 
sidered necessary.  (It  is  certain  that  anything  deserving  the  name  of 
milk  fever  is  now  altogether  exceptional,  and  such  feverishness  as  exists 
is  generally  c|uite  transient.,'  It  is  also  a  fact  that  it  is  most  apt  to 
occur  in  delicate  and  weakly  women,  especially  in  those  who  do  not 
or  are  unable  to  nurse.  There  does  not,  however,  seem  to  be  any 
sufficient  reason  for  referring  it,  even  when  tolerably  well  marked,  to 
septiceemia.  The  relief  which  attends  the  emptying  of  the  Ijreasts 
seems  sufficient  to  prove  its  counection  with  lactation,  and  the  discom- 
fort which  is  necessarily  associated  with  the  swollen  and  turgid  manim8& 
is  of  itself  quite  sufficient  to  explain  it. 

In  the  urine  of  women  dui'ing  lactation  an  appreciable  amount  of 
sugar  may  readily  be  detected.  The  amount  varies  according  to  the 
condition  of  the  breasts.  It  increases  when  they  are  turgid  and  con- 
gested, and  is  therefore  most  abundant  in  women  in  whom  the  breasts 
are  not  emptied,  as  when  the  child  is  dead  or  when  lactation  is  not 
attempted. 

Contraction  of  the  Uterus  after  Delivery. — Immediately  after 
delivery  the  uterus  contracts  firmly,  and  can  be  felt  at  the  loAver  part 
of  the  abdomen  as  a  hard,  firm  mass  about  the  size  of  a  cricket-ball 
(Plate  v.).  After  a  time  it  again  relaxes  somewhat,  and  alternate 
relaxations  and  contractions  go  on  at  intervals  for  a  considerable  time 
after  the  expulsion  of  the  placenta.  The  more  complete  and  perma- 
nent the  contraction,  the  greater  the  safety  and  comfort  of  the  patient ; 
for  when  the  organ  remains  in  a  state  of  partial  relaxation,  coagula  are 
apt  to  be  retained  in  its  cavity,  while  for  the  same  reason  air  enters  more 
readily  into  it.  Hence  decomposition  is  favored,  and  the  chances  of 
septic  absorption  are  much  increased,  while  even  when  this  does  not 
occur  the  muscular  fibres  are  excited  to  contract  and  severe  after-pains 
are  produced. 

After  the  first  few  days  the  diminution  in  the  size  of  the  uterus  pro- 
gresses with  great  rapidity.  'By  about  the  sixth  day  it  is  so  much  less- 
ened as  to  project  not  more  than  H  or  2  inches  above  the  pelvic  brim,^ 
while  bv  the  eleventh  day  it  is  no  longer  to  be  made  out  by  abdominal 
palpation.     Its  increased  size  is,  however,  still  apparent  per  vaginam, 

'  Dublin  Quarterly  Journ.  of  Med.  Science,  1878,  vol.  Ixv.  p.  435. 


S" 

13. 

a 

CO 

S"  5: 

l§ 

o  d. 

■_,         ?i      p 

S"  o 


% 


g  ?= 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.  555 

and  should  occasion  arise  for  making  internal  examination,  the  mass  of 
the  lower  segment  of  the  uterus,  with  its  flabby  and  patulous  cervix, 
can  be  felt  for  some  weeks  after  delivery.  This  may  sometimes  be  of 
practical  value  in  cases  in  which  it  is  necessary  to  ascertain  the  fact  of 
recent  delivery,  and  under  these  circumstances,  as  pointed  out  by  Simp- 
son, the  uterine  sound  would  also  enable  us  to  prove  that  the  cavity  of 
the  uterus  is  considerably  elongated.  ( Indeed,  the  normal  condition  of 
the  uterus  and  cervix  is  not  regained  until  six  weeks  or  two  months 
after  labor.  \These  observations  are  corroboraleaby  investigations  on 
the  weight  of  the  organ  at  different  periods  after  labor.  Thus,  Heschl  ^ 
has  shown  that  the  uterus  immediately  after  delivery  weighs  about  22 
to  24  oz.;  within  a  week  it  weighs  19  to  21  oz.,  and  at  the  end  of  the 
second  week  10  to  11  oz.  only.  At  the  end  of  the  third  week  it  weighs 
5  to  7  oz.,  but  it  is  not  until  the  end  of  the  second  month  that  it  reaches 
its  normal  weight.  Hence  it  appears  that  the  most  rapid  diminution 
occurs  during  the  second  week  after  delivery. 

Fatty  Transformation  of  the  Muscular  Pibres.^The  mode  in 
which  this  diminution  in  size  is  effected  is  by  the  transformation  of  the 
muscular  fibres  into  molecular  fat,  which  is  absorbed  into  the  maternal 
vascular  system,  which  therefore  becomes  loaded  with  a  large  amount 
of  eifete  material. )  Heschl  has  shown  that  the  entire  mass  of  the 
enlarged  uterine  muscles  is  removed,  and  replaced  by  newly-formed 
fibres,  which  commence  to  be  developed  about  the  fourth  week  after 
delivery,  the  change  being  complete  about  the  end  of  the  second  month. 
Generally  speaking,  involution  goes  on  without  interruption.  It  is, 
however,  apt  to  be  interfered  with  by  a  variety  of  causes,  such  as  pre- 
mature exertion,  intercurrent  disease,  and  very  probably  by  neglect  of 
lactation.  Hence  the  uterus  often  remains  large  and  bulky,  and  the 
foundation  for  many  subsequent  uterine  ailments  is  laid. 

Changes  in  the  Uterine  Vessels. — Williams  has  drawn  attention 
to  changes  occurring  in  the  vessels  of  the  uterns,(some  of  which  seem 
to  be  permanent,]  and  may,  should  further  observations  corroborate  his 
investigations,  prove  of  value  in  enabling  us  to  ascertain  whether  a 
uterus  is  nulliparous  or  the  reverse — a  question  which  may  be  of  medico- 
legal importance.  After  pregnancy  he  found  all  the  vessels  enlarged 
injsalibre.  The  coats  of  the  arteries  are  thickened  and  hypertrophied, 
and  this"  he  has  observed  even  in  the  uteri  of  aged  women  who  have 
not  borne  children  for  many  years.  The  venous  sinuses,  especially  at 
the  placental  site,  have  their  walls  greatly  thickened  and  convoluted, 
and  contain  in  their  centre  a  small  clot  of  blood  (Fig.  196).  This 
thickening  attains  its  greatest  dimensions  in  the  third  montii  after  gesta- 
tion, but  traces  of  it  may  be  detected  as  late  as  ten  or  twelve  weeks  after 
labor. 

Changes  in  the  Uterine  Mucous  Membrane. — The  changes  going 
on  in  the  lining  membrane  of  the  uterus  immediately  after  delivery 
are  of  great  importance  in  leading  to  a  knowledge  of  the  puerperal 
state,  and  have  already  been  discussed  when  describing  the  decidua 
(p.  105).  Its  cavity  is  covered  with  a  reddish-gray  film  formed  of  blood 
and  fibrin.     The  open  mouths  of  the  uterine  sinuses  are  still  visible, 

'  Researches  on  the  Conduct  of  the  Human  Uterus  after  Delivery. 


556 


THE  PUERPERAL  STATE. 


more  especially  over  the  site  of  the  placenta,  and  throiul^i  may  be  seen 
projecting  from  them.  The  placental  site  can  be  cli.stini;'tly  ma^e  out  in 
the  form  of  an  irregularly  oval  patch,  where  the  lining  membrane  is 
thicker  than  elsewhere.     (See  Plate  Y.) 

Contraction  of  the  Vagina,  etc. — The  vagina  soon  contracts,  and 
by  the  time  the  puerperal  month  is  over  it  has  returned  to  its  normal 

Fig.  196. 


Section  of  a  Uterine  Sinus  from  the  Placental  Site  Xine  Weeks  after  Delivery. 
(After  Williams.) 

dimensions,  but  after  childbearing  it  always  remains  more  lax  and  less 
rugose  than  in  uulliparse.  The  vulva,  at  first  very  lax  and  much  dis- 
tended, soon  regains  its  former  state.  The  abdominal  parietes  remain 
loose  and  flabby  for  a  considerable  time,  and  the  white  streaks  produced 
by  the  distension  of  the  cutis  very  generally  become  permanent.  In 
some  women,  especially  when  proper  support  by  bandaging  has  not  been 
given,  the  abdomen  remains  permanently  loose  and  pendulous. 

The  Lochial  Discharge. -4-From  the  time  of  delivery  up  to  about 
three  weeks  afterward  a  discharge  escapes  from  the  interior  of  the  uterus 
known  as  the  lochia  a  At  JSjust  this  consists  almost  entirely  of  pure 
blood,  mixed  with  a  variable  amount  of  coagula.  If  efficient  uterine 
contraction  has  not  been  secured  after  the  expulsion  of  the  placenta, 
coagula  of  considerable  size  are  frequently  expelled  with  the  lochia  for 
one  or  tsvo  days  after  delivery.  In  three  or  four  days  the  distinctly 
bloody  character  of  the  lochia  is  altered.  They  have  a  reddish  watery 
appearance,  and  are  known  as  the  lochia  rubra  or  antenia.  According 
to  the  researches  of  AVertheimer,^  they  are  at  this  time  composed  chiefly 
of  blood-corpuscles,  mixed  with  epithelium  scales,  mucous  corj^uscles, 

^  Virchoiv's  Arch.,  1861. 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.         557 

and  the  debris  of  the  decidua.  Tlie  cliange  in  the  appearance  of  the 
discharge  progresses  gradually,  and  about  the  seventh  or  eighth  day  it 
has  uo  longer  a  red  color,  but  is  a  pale  gi'eenish  fluid,  with  a  peculiar 
sickening  and  disagreeable  odor,  and^  is  familiarly  described  as  the 
"  green  waters."  It  now  contains  a  small  quantity  of  blood-corpuscles, 
which  lessens  in  amount  from  day  to  day,  but  a  considerable  number 
of  pus-corpuscles,  which  remain  the  principal  constituent  of  the  dis- 
charge until  it  ceases.  Besides  these,  epithelial  scales,  fatty  granules, 
and  crystals  of  cholesterin  are  observed.  Occasionally  a  small  infuso- 
rium, which  has  been  named  the  Trichomonas  vaginalis,  has  been 
detected,  but  it  is  not  of  constant  occurrence. 

The  anioiiiit  of  tlie  lochia  varies  much,  and  in  some  women  it  is 
habitually  more  al)imdant  than  in  others.  Under  ordinary  circum- 
stances it  is  very  scanty  after  the  first  fortnight,  but  occasionally  it  con- 
tinues somewhat  abundant  for  a  month  or  more,  without  any  bad  results. 
/It  is  apt  again  to  become  of  a  red  color  and  to  increase  in  quantity 
in  consequence  of  any  slight  excitement  or  disturbance.  \  If  this  red 
discharge  continues  for  any  undue  length  of  time,  there  is  reason  to 
suspect  some  abnormality,  and  it  may  not  unfrequently  be  traced  to 
slight  lacerations  about  the  cervix  which  have  not  healed  properly. 
This  result  may  also  follow  premature  exertion,  interfering  with  the 
proper  involution  of  the  uterus ;  and  the  patient  should  certainly  not 
be  allowed  to  move  about  as  long  as  much  colored  discharge  is  going  on. 

Occasionally  the  lochia  has  an  intensely  fetid  odor.  This  must 
always  give  rise  to  some  anxiety,  since  it  often  indicates  the  retention 
and  putrefaction  of  coagula  and  involves  the  risk  of  septic  absorption. 
It  is  not  very  rare,  however,  to  observe  a  most  disagreeable  odor  persist 
in  the  lochia  without  any  bad  results^  /The  fetor  always  deserves  care- 
ful attention,  and  an  endeavor  should  be  made  to  obviate  it  by  direct- 
ing the  nurse  to  syringe  out  the  vagina  freely  night  and  morning  with 
Cgndy's  fluid  and  water;  while,  if  it  be  associated  with  quickened  pulse 
and  elevated  temperature,  other  measures,  to  be  subsequently  described, 
will  be  necessary. 

The  after-pains,  which  many  childbearing  women  dread  even  morei 
than  the  labor-pains,  are  irregular  contractions  occurring  for  a  varying  j 
time  after  delivery,  and  resulting  from  the  efforts  of  the  uterus  to  expel  * 
coagula  which  have  formed  in  its  interior.!  If,  therefore,  special  care 
be  taken  to  secure  complete  and  permanent  contraction  after  labor,  they 
rarely  occur  or  to  a  very  slight  extent.  )  Their  dependence  on  uterine 
inertia  is  evidenced  by  the  common  observation  that  (they  are  seldom 
met  with  in  primiparse^  in  whom  uterine  contraction  may  be  supposed 
to  be  more  efficient,  and  are  more  frequent  in  women  who  have  borne 
many  children.'  They  are  a  preventable  complication,  and  one  which 
need  not  give  rise  to  any  anxiety :  they  are,  indeed,  rather  salutary  than 
the  reverse,  for  if  coagula  be  retained  in  utero,  the  sooner  they  are 
expelled  the  better.  The  after-pains  generally  begin  a  few  hours  after 
delivery,  and  continue  in  bad  cases  for  three  or  four  days,  but  seldom 
longer.  They  are  generally  increased  when  the  mammae  are  irritated 
by  suction.  When  at  their  height  they  are  often  relieved  by  the  expul- 
sion of  the  coagula.     In  some  severe  cases  they  are  apparently  neural- 


558  THE  PUERPERAL  STATE. 

gic  in  character,  and  do  not  seem  to  depend  on  the  retention  of  coagula. 
They  may  be  readily  distinguished  from  pains  due  to  more  serious 
causes  bv  feeling  the  enlarged  uterus  harden  under  their  influence,  by 
the  uterus  not  being  tender  on  pressure,  and  by  the  absence  of  any 
constitutional  symptoms. 

The  manag-ement  of  -women  after  childbirth  has  varied  much  at 
different  times,  according  to  fashion  or  theory.  The  dread  of  inflam- 
mation long  influenced  the  professional  mind,  and  caused  the  adoption 
of  a  strictly  antiphlogistic  diet,  which  led  to  a  tardy  convalescence. 
The  recognition  of  the  essentially  physiological  character  of  labor  has 
resulted  in  more  sound  views,  with  manifest  advantage  to  our  patients. 
The  main  facts  to  bear  in  mind  with  regard  to  the  puerperal  woman 
are  her  nervous  susceptibility,  which  necessitates  quiet  and  absence  of 
all  excitement ;  the  importance  of  favoring  involution  by  prolonged 
rest ;  and  the  risk  of  septicsemia,  which  calls  for  perfect  cleanliness  and 
attention  to  hygienic  precautions. 

As  soon  as  we  are  satisfied  that  the  uterus  is  perfectly  contracted  and 
that  all  risk  of  hemorrhage  is  over,  the  patient  should  be  left  to  sleep. 
^Many  practitioners  administer  an  opiate;  but  as  a  matter  of  routine 
^this  is  certainly  not  good  practice,  since  it  checks  the  contractions  of  the 
luterus  and  often  produces  unpleasant  effects.  Still,  if  the  labor  have 
been  long  and  tedious,  and  the  patient  be  much  exhausted,  fifteen  or 
twenty  drops  of  Battley's  solution  may  be  administered  with  advan- 
tage. 

Within  a  few  hours  the  patient  should  be  seen,  and  at  the  first  visit 
particular  attention  should  be  paid  to  the  state  of  the  pulse,  the  uterus, 
and  the  bladder.  The  pulse  during  the  whole  period  of  convalescence 
should  be  carefully  watched,  and  if  it  be  at  all  elevated  the  tempera- 
ture should  at  once  be  taken.  If  the  pulse  and  temperature  remain 
normal,  we  may  be  satisfied  that  things  are  going  on  well ;  but  if  the 
one  be  quickened  and  the  other  elevated  some  disturbance  or  complica- 
tion may  be  apprehended.  The  abdomen  should  be  felt,  to  see  that 
the  uterus  is  not  unduly  distended  and  that  there  is  no  tenderness. 
After  the  first  day  or  two  this  is  no  longer  necessary. 

Treatment  of  Retention  of  Urine. — Sometimes  the  patient  cannot 
at  first  void  the  urine,  and  the  application  of  a  hot^_sjx)ng;e_  over  the 
pubes  may  enable  her  to  do  so.  If  the  retention  of  urine  be  due  to 
temporary  paralysis  of  the  bladder,  three  or  four  20-minim  doses  of  the 
liquid  extract  of  ergot  at  intervals  of  half  an  hour  may  prove  success- 
ful. Many  hours  should  not  be  allowed  to  elapse  without  relieving 
the  patient  by  the  catheter,  since  prolonged  retention  is  only  likely  to 
make  matters  worse.~™'Subsequently,  it  may  be  necessary  to  empty  the 
bladder  night  and  morning  until  the  patient  regain  her  power  over  it 
or  until  the  swelling  of  the  urethra  subsides,  and  this  will  generally  be 
the  case  in  a  few  days.  Occasionally  the  bladder  becomes  largely  dis- 
tended, and  is  relieved  to  some  degree  by  dribbling  of  urine  from  the 
urethra.  Such  a  state  of  things  may  deceive  the  patient  and  nurse,  and 
may  produce  serious  consequences  by  causing  cystitis.  Attention  to  the 
condition  of  the  abdomen  will  prevent  the  practitioner  from  being 
deceived,  for  in  addition  to  some  constitutional  disturbance  a  large,  ten- 


THE  PUERPERAL   STATE  AXD  ITS  MAXAGEMEXT.  559 

der,  and  fluctuating  swelling  will  be  fuund  in  the  hypogastric  region 
distinct  from  the  uterus,  which  it  displaces  to  one  or  other  side.  The 
catheter  will  at  once  prove  that  this  is  produced  by  distension  of  the 
bladder. 

Treatment  of  Severe  After-pains. — If  the  after-pains  be  very/ 
severe  an  o^jiate  may  be  administered,  or  if  the  lochia  be  not  over- 
abtmdaut  a  linseed-meal  poultice  sprinkled  with  laudanum  or  with  the 
chloroform  and  belladonna  liniment  may  be  applied.  If  proper  care 
have  been  taken  to  induce  uterine  contraction,  they  will  seldom  be  suffi- 
ciently severe  to  require  treatment.  In  America  quinine  in  doses  of  ten 
grains  twice  daily  has  been  strongly  recommendec!7  especially  when 
opiates  fail  and  when  the  pains  are  neuralgic  in  character;  and  I  have 
found  this  remedy  answer  extremely  well.  The  quinine  is  best  given 
in  solution  with  ten  or  fifteen  minims  of  hydrobromic  acid,  which 
materially  lessens  the  unpleasant  head  symptoms  often  accompanying 
the  administration  of  such  large  doses.  The  inhalation  of  the  nitrite 
of^myl  in  severe  cases  is  said  to  be  very  efficaciotis.^  "" 

Diet  and  Reg-imen. — The  diet  of  the  puerperal  patient  claims  care- 
ful attention,  the  more  so  as  old  prejudices  in  this  respect  are  as  yet  far 
from  exploded,  and  as  it  is  by  no  means  rare  to  find  mothers  and  nurses 
who  still  cling  tenaciously  to  the  idea  that  it  is  essential  to  prescribe  a 
lo"w  regimen  for  many  days  after  labor.  The  erroneousness  of  this  j^lan 
is  now  so  thoroughly  recognized  that  it  is  hardly  necessary  to  argue  the 
point.  There  is,  however,  a  tendency  in  some  to  err  in  the  opposite 
direction,  which  leads  them  to  insist  on  the  patient's  consuming  solid 
food  too  soon  after  delivery,  before  she  has  regained  her  appetite,  therebv 
producing  nausea  and  intestinal  derangement.  \Our  best  guide  in  this 
matter  is  the  feeling  of  the  patient  herself.^  If,  as  is  often  the  case,  she 
be  disinclined  to  eat,  there  is  no  reason  why  she  should  be  urged  to  do 
so.  A  good  cup  of  beef-tea,  some  bread  and  milk,  or  an  egg  beat  up 
Avith  milk  may  generally  be  given  with  advantage  shortly  after  deliven-, 
and  many  patients  are  not  inclined  to  take  more  for  the  first  dav  or  so. 
If  the  patient  be  hungry,  there  is  no  reason  why  she  should  not  have 
some  more  solid  btit  easily  digested  food,  such  as  white  fish,  chicken,  or 
sweetbread,  and  after  a  day  or  two  she  may  resume  her  ordinarv  diet, 
bearing  in  mind  that,  being  confined  to  bed,  she  cannot  with  advantage 
constime  the  same  amount  of  solid  food  as  when  she  is  up  and  about. 
Dr.  Oldham,  in  his  presidential  address  to  the  Obstetrical  Society,"  has 
some  apposite  remarks  on  this  point,  which  are  worthy  of  quotation: 
^^  A  puerperal  month  under  the  guidance  of  a  monthly  nurse  is  easilv 
di'awn  out,  and  it  is  well  if  a  love  of  the  comforts  of  illness  and  the 
persuasion  of  being  delicate,  which  are  the  infirmities  of  many  women, 
do  not  induce  a  feeble  life  which  long  survives  after  the  occasion  of  it 
is  forgotten.  I  know  no  reason  why,  if  a  woman  is  confined  earlv  in 
the  morning,  she  should  not  have  her  breakfast  of  tea  and  toast  at  nine, 
her  luncheon  from  some  digestible  meat  at  one,  her  cup  of  tea  at  five, 
her  dinner  with  chicken  at  seven,  and  her  tea  again  at  nine,  or  the 
equivalent,  according  to  the   variation   of  her  habits    of  living.     Of 

^Mr.  F.  "W.  Kendle,  Lancet.  1887.  vol.  i.  p.  606. 
2  Obstet.  Tram.,  1865,  vol.  vi.  p.  14. 


560  THE  PUERPERAL  STATE. 

course  there  is  the  common-sense  selection  of  articles  of  food,  guarding 
against  excess  and  avoiding  stimulants.  (  But  gruel  and  slops  and  all 
intermediate  feeding  are  to  be  avoided.')  No  one  who  has  seen  both 
methods  adopted  can  fail  to  have  been  struck  with  the  more  rapid  and 
satisfactory  convalescence  which  takes  place  when  the  patient's  strencrth 
is  not  weakened  by  an  unnecessarily  low  diet.  Stimulants,  as  a  rule,  are 
not  required ;  but  if  the  patient  be  weakly  and  exhausted,  or  if  she  be 
accustomed  to  their  use,  there  can  be  no  reasonable  objection  to  their 
judicious  administration. 

Immediately  after  delivery  a  warm  napkin  is  applied  to  the  vulva^ 
and  after  the  patient  has  rested  alittle  the  nurse  removes  the  soiled 
linen  from  the  bed  and  washes  the  external  genitals.  It  is  impossible 
to  pay  too  much  attention  during  the  subsequent  progress  of  the  case 
to  the  maintenance  of  perfect  cleanliness.  Perfectly  antiseptic  mid- 
wifery is  no  doubt  an  impossibility,  but  a  near  approach  to  it  may  be 
made,  and  the  greater  the  care  taken  the  more  certainly  will  the  safety 
of  the  patient  be  ensured.^  It  will  be  a  wise  precaution  to  advise  the 
nurse  never  to  touch  the  genitals  for  the  first  few  days  unless  her  hands 
have  been  moistened  in  a  l-in-20  solution  of  carbolic  acid  or  1-in-lOOO 
solution  of  perchloride  of  mercury,  or  lubricated  with  carbolized  vase- 
line. The  linen  should  be  frequently  changed,  and  all  dirty  linen  and 
discharges  immediately  removed  from  the  apartment.  The  vulva  should 
be  washed  daily  with  a  solution  of  perchloride  of  mercury  of  the  strength 
of  l-in-2000,  or  with  Condy's  fluid  and  water,  and  the  patient  will 
derive  great  comfort  from  having  the  vagina  syringed  gently  out  once 
a  day  with  the  same  solution.  It  is  well  also  to  have  the  vulva  thor- 
oughly washed  with  corrosive-sublimate  lotion  at  the  commencement 
of  labor,  and  the  vagina  syringed  at  the  same  time.  The  remarkable 
diminution  of  mortality  which  has  followed  such  antiseptic  precautious 

^  The  following  rules  I  have  for  the  past  year  or  two  distributed  to  the  monthly- 
nurses  attending  my  own  patients,  with  the  result,  I  believe,  of  a  marked  improve- 
ment in  their  comfort  and  a  more  generally  satisfactory  convalescence : 

Antiseptic  Kules  for  Monthly  Ntjkses. 

1.  Two  bottles  are  supplied  to  each  patient.  One  contains  a  mixture  of  perchloride 
of  mercury  of  the  strength  of  1  part  to  1000  of  water  (called  the  1-in-lOOO  solution), 
the  other  carbolized  vaseline  (1  in  8). 

2.  A  small  basin  containing  the  1-in-lOOO  solution  must  always  stand  by  the  bedside 
of  the  patient,  and  the  nurse  must  thoroughly  rinse  her  hands  in  it  every  time  she  touches 
the  patient  in  the  neighborhood  of  the  genital  organs,  for  washing  or  any  other  pur- 
pose whatsoever,  before  or  during  labor  and  for  a  week  after  delivery. 

3.  All  sponges,  vaginal  and  rectal  pipes,  catheters,  etc.  must  be  dipped  in  the  1-in- 
1000  solution  before  being  used.  The  surfaces  of  slippers,  bedpans,  etc.  should  also  be 
sponged  with  it. 

4.  Vaginal  pipes,  enema-tubes,  catheters,  etc.  should  be  smeared  with  the  carbolized 
vaseline  before  use. 

5.  Unless  express  directions  are  given  to  the  contrary,  the  vagina  should  be  syringed 
twice  daily  after  delivery  with  the  1-in-lOOO  solution,  with  an  equal  quantity  of  hot 
water  added  to  it. 

6.  All  water  used  for  washing  should  have  sufficient  Condy's  fluid  dropped  into  it  to 
give  it  a  pale  pink  color. 

7.  All  soiled  linen,  diapers,  etc.  should  be  immediately  removed  from  the  bedroom! 
N.B. — These  rules  are  for  the  purpose  of  protecting  the  patient  from  the  risk  arising 

from  accidental  contamination  of  the  hands,  sponges,  etc.  It  is,  therefore,  hoped  that 
they  will  be  faithfully  and  minutely  adhered  to. 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.  561 

in  lying-in  hospitals  well  shows  the  importance  of  these  measures.  The 
room  should  be  kept  tolerably  cool  and  fresh  air  freely  admitted. 

It  is  customary,  on  the  morning  of  the  second  or  thirclday,  to  secure 
an  action  of  the  bowels ;  and  there  is  no  better  way  of  doing  this  than 
by  a  large  enema  of  soap  and  water.  If  the  patient  object  to  this  and 
the  bo\veTB  have  not  acted,  some  mild  aperient  may  be  administered, 
such  as  a  small  dose  of  castor  oil,  a  few  grains  of  coLgcynth-and-heu- 
bane  pill,  or  the  popular  French  aperient,  the  "  Tamar  Indien." 

The  management  of  suckling  and  of  the  breasts  forms  an  important 
part  of  the  duties  of  the  monthly  nurse  which  the  practitioner  should 
himself  superintend.  This  will  be  more  conveniently  discussed  under 
the  head  of  lactation. 

Importance  of  Prolonged  Rest. — The  most  important  part  of  the 
management  of  the  puerperal  state  is  the  securing  to  the  patient  pro- 
loRgSfLrest  in  the  horizontal  position  in  order  to  favor  proper  involu- 
tion of  the  uterus.  For  the  first  few  days  she  should  be  kept  as  quiet 
and  still  as  possible,  not  receiving  the  visits  of  any  but  her  nearest  rela- 
tives, thus  avoiding  all  chance  of  undue  excitement.  It  is  customary 
among  the  better  classes  for  the  patient  to  remain  in  bed  for  eight  or 
tenjkys,  but,  provided  she  be  doing  well,  there  can  be  no  objection  to 
her  lying  on  the  outside  of  the  bed  or  slipping  on  to  a  sofa  somewhat 
sooner.  After  ten  days  or  a  fortnight  she  may  be  permitted  to  sit  on  a 
chair  for  a  little,  but  I  am  convinced  that  the  longer  she  can  be  per- 
suaded to  retain  the  recumbent  position,  the  more  complete  and  satis- 
factory will  be  the  progress  of  involution ;  and  she  should  not  be  allowed 
to  walk  about  until  the  thh'd  week,  about  which  time  she  may  also  be 
permitted  to  take  a  drive.  If  it  be  borne  in  mind  that  it  takes  from 
six  weeks  to  two  months  for  the  uterus  to  regain  its  natural  size,  the 
reason  for  prolonged  rest  will  be  obvious.  The  judicious  practitioner, 
however,  while  insisting  on  this  point,  will  take  measures  at  the  same 
time  not  to  allow  the  patient  to  lapse  into  the  habits  of  an  invalid  or 
to  give  the  necessary  rest  the  semblance  of  disease. 

Subsequent  Treatment. — Toward  the  termination  of  the  puerperal 
month  some  slij;ht  tonic,  such  as  small  doses  of  quinine  with  phosphoric 
acid,  may  be  often  given  with  advantage,  especially  if  convalescence  be 
tardy.  Nothing  is  so  beneficial  in  restoring  the  patient  to  her  usual 
health  as  change  of  air,  and  in  the  upper  classes  a  short  visit  to  the 
seaside  may  generally  be  recommended,  with  the  certainty  of  much 
benefit. 

36 


562  THE  PUEBPEBAL  STATE. 


CHAPTER   II. 

MANAGEMENT    OF    THE    INFANT,    LACTATION,   ETC. 

Commencement  of  Respiration. — Almost  immediately  after  its 
expulsion  a  healthy  cliild  cries  aloud,  thereby  showing  that  respiration 
is  established ;  and  this  may  be  taken  as  a  signal  of  its  safety.  The 
first  respiratory  movements  are  excited  partially  by  reflex  action  result- 
ing from  the  contact  of  the  cold  external  air  with  the  cutaneous  nerves, 
and /partly  by  the  direct  irritation  of  the  medulla  oblongata  in  conse- 
quence of  the  circulation  through  it  of  blood  no  longer  oxygenated  in 
the  placenta.) 

Apparent  Death  of  the  Ne^wborn  Child. — Not  infrequently  the 
child  is  born  in  an  apparently  lifeless  state.  This  is  especially  likely 
to  be  the  case  when  the  second  stage  of  labor  has  been  unduly  prolonged, 
so  that  the  head  has  been  subjected  to  long-continued  pressure.  The 
utero-placental  circulation  is  also  apt  to  be  injuriously  interfered  with 
before  the  birth  of  the  child  when  a  tardy  labor  has  produced  tonic 
contraction  of  the  uterus  and  consequent  closure  of  the  uterine  sinuses, 
or,  more  rarely,  from  such  causes  as  the  injudicious  administration  of 
ergot,  premature  separation  of  the  placenta,  or  compression  of  the 
umbilical  cord.  In  any  of  these  cases  it  is  probable  that  the  arrest  of 
the  utero-placental  circulation  induces  attempts  at  inspiration  which  are 
necessarily  fruitless,  since  air  cannot  reach  the  lungs,  and  the  foetus  may 
die  asphyxiated,  the  existence  of  the  respiratory  movement  being  proved 
on  post-mortem  examination  by  the  presence  in  the  lungs  of  liquor  amnii, 
mucus,  and  meconium,  and  by  the  extravasation  of  blood  from  the  rup- 
ture of  their  engorged  vessels. 

In  most  cases,  when  the  child  is  born  in  a  state  of  apparent  asphyxia 
its  face  is  swollen  and  of  a  dark  livid  color.  It  not  infrequently  makes 
one  or  two  feeble  and  gasping  efforts  at  respiration,  without  any  definite 
cry ;  on  auscultation  the  heart  may  be  heard  to  beat  weakly  and  slowly. 
Under  such  circumstances  there  is  a  fair  hope  of  its  recovery.  In  other 
cases  the  child,  instead  of  being  turgid  and  livid  in  the  face,  is  pale, 
with  flaccid  limbs  and  no  appreciable  cardiac  action  ;  then  the  prognosis 
is  much  more  unfavorable. 

Treatment  of  Apparent  Death. — No  time  should  be  lost  in  endeav- 
oring to  excite  respiration,  and  at  first  this  must  be  done  by  applying 
suitable  stimulants  to  the  cutaneous  nerves  in  the  hope  of  exciting 
reflex  actionT^The  cord  should  be  at  once  tied  and  the  child  removed 
from  the  mother,  for  tlie  final  uterine  contractions  have  so  completely 
arrested  the  utero-jjlacental  circulation  as  to  render  it  no  longer  of  any 
value.  If  the  face  be  very  livid,  a  few  drops  of  blood  may  with  advan- 
tage be  allowed  to  flow  from  the  cord  before  it  is  tied,  with  the  view  of 
relieving  the  embarrassed  circulation.    Very  often  some  slight  stimulus, 


MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC.  563 

such  as  one  or  two  sharp  slaps  on  the  thorax  oif  rapidly  rubbing  the 
body  with  brandy  poured  into  the  palms  of  the  hands,  will  suffice  to 
induce  respiration.  Failing  this,  nothing  acts  so  well  as  the  sudden  and 
instantaneous  application  of  heat  and  cold.  For  this  purpose  extremely 
hot  water  is  placed  in  one  basin,  arid  quite  cold  water  in  another.  Tak- 
ing the  child  by  the  shoulders  and  legs,  it  should  be  dipped  for  a  single 
moment  into  the  hot  water,  and  then  into  the  cold ;  and  these  alternate 
applications  may  be  repeated  once  or  twice  as  occasion  requires.  The 
eifect  of  this  measure  is  often  very  marked,  and  I  have  frequently  seen 
it  succeed  Avhen  prolonged  efforts  at  artificial  respiration  have  been  made 
in  vain. 

If  these  means  fail,  an  endeavor  must  be  at  once  made  to  carry 
on  respiration ,  artificially.  The  best  means  of  doing  this  have  been 
exhaustively  studied  by  Dr.  Champneys,^  who  considers  the  only  two 
reliable  means  of  carrying  on  artificial  respiration  are  those  of  Schultze 
and  Sylvester.  fThe  Sylvester  method  is,  on  the  whole,  that  w^iich  is 
most  easily  applied,  anaon  account  of  the  compressibility  of  the  thorax 
it  is  peculiarly  suitable  for  infants.  The  child  being  laid  on  its  back 
Avith  the  shoulders  slightly  elevated  and  the  feet  held  in  an  elongated 
position  by  an  assistant,  the  elbows  are  grasped  by  the  operator  and 
alternately  raised  above  the  head  and  slowly  depressed  against  the  sides, 
of  the  thorax,  so  as  to  produce  the  efi^ect  of  inspiration  and  expiration,/ 
If  this  do  not  succeed,  the  Marshall  Hall  method  may  be  substituted, 
and  one  or  more  of  the  plans  of  exciting  reflex  action  through  the 
cutaneous  nerves  may  be  alternated  with  it. 

Other  means  of  exciting  respiration  have  been  recommended.  One 
of  them,  much  used  abroad,  is  the  artificial  insufflation  of  the  lungs  by 
means  of  a  flexible  catheter  guided  into  the  glottis  or  by  placing  a  hand- 
kerchief over  the  child's  mouth  and  directly  insufflating  the  lungs.  It 
is  not  difficult  to  pass  the  end  of  a  catheter  into  the  glottis,  using  the 
little  finger  as  a  guide ;  and,  once  in  position,  it  may  be  used  to  blow 
air  gently  into  the  lungs,  which  is  expelled  by  compression  on  the 
thorax,  the  insufflation  being  repeated  at  short  intervals  of  about  ten 
seconds.  One  advantage  of  this  plan  is  that  it  allows  the  liquor  amnii 
and  other  fluids  which  may  have  been  drawn  into  the  lungs  in  the  pre- 
mature efforts  at  respiration  before  birth  to  be  sucked  up  into  the  cath- 
eter, and  so  removed  from  the  lungs.  Dr.  Champneys  recommends 
that  when  the  catheter  is  passed  into  the  trachea  for  about  three  inches 
from  the  child's  mouth,  the  thorax  should  be  gently  compressed,  and 
then  air  should  be  blown  through  the  catheter.  The  effect  of  this 
manoeuvre  is  that  any  mucus  or  fluid  in  the  trachea  passes  upward 
through  the  glottis  into  the  pharynx.  The  same  effect  may  be  produced, 
but  less  perfectly,  by  placing  the  hand  over  the  nostrils  of  the  child, 
blowing  into  its  mouth,  and  immediately  afterward  comjjressing  the 
thorax.  One  of  these  methods  should  certainly  be  tried  if  all  other 
means  have  failed.  Faradization  along  the  course  of  the  phrenic  nerves 
is  a  promising  means  of  inducing  respiration  which  should  be  used  if 
the  proper  apparatus  can  be  procured.  Encouragement  to  persevere  in 
our  endeavors  to  resuscitate  the  child  may  be  derived  from  the  numer- 

^  Medico-Chir.  Trans.,  vol.  Ixiv.  pp.  41,  87,  and  vol.  Ixv.  p.  75. 


564  THE  PUERPERAL  STATE. 

ous  authenticated  instances  of  success  after  the  lapse  of  a  considerable 
time,  even  of  an  hour  or  more.  As  long  as  the  cardiac  pulsations  con- 
tinue, however  feebly,  there  is  no  reason  to  despair ;  and  Champneys 
has  collected  some  apparently  authenticated  cases  in  which  children 
seemingly  dead  have  been  buried  for  some  hours  and  then  dug  up 
and  restored  to  life. 

"Washing-  and  Dressing  of  the  Child. — When  the  child  cries  lus- 
tily from  the  first,  it  is  customary  for  the  nurse  to  wash  and  dress  it  as 
soon  as  her  immediate  attendance  on  the  mother  is  no  longer  required. 
For  this  purpose  it  is  placed  in  a  bath  of  warm  water  and  carefully 
soaped  and  sponged  from  head  to  foot.  With  the  view  of  facilitating 
the  removal  of  the  unctuous  material  with  Avhich  it  is  covered,  it  is 
usual  to  anoint  it  with  cold  cream  or  olive  oil,  which  is  washed  off  in 
the  bath.  Nurses  are  apt  to  use  undue  roughness  in  endeavoring  to 
remove  every  particle  of  the  vernix  caseosa,  small  portions  of  which 
are  often  firmly  adherent.  Tkis^-ffiistake  should  be  avoided,  as  these 
particles  will  soon  dry  up  and  become  spontaneously  detached.  The 
cord  is  generally  wrapped  in  a  small  piece  of  charred  linen,  which  is 
supposed  to  have  some  slight  antiseptic  property,  and  this  is  renewed 
from  day  to  day  until  the  cord  has  withered  and  separated.  This  gen- 
erally occurs  Avithin  a  week;  and  a  small  pad  of  soft  linen  is  then 
placed  over  the  umbilicus  and  supported  by  a  flannel  belly-band  placed 
around  the  abdomen,  which  shoulcl  not  be  too  tight  for  fear  of  embar- 
rassing the  respiration.  By  this  means  the  tendency  to  umbilical  hernia 
is  prevented. 

The  clothing  of  the  infant  varies  according  to  fashion  and  the  cir- 
cumstances of  the  parents.  The  important  points  to  bear  in  mind  are 
that  it  should  be  warm  (since  newly-born  children  are  extremely  sus- 
ceptible to  cold),  and  at  the  same  time  light  and  sufficiently  loose  to 
allow  free  play  to  the  limbs  and  thorax.  All  tight  bandaging  and 
swaddling,  such  as  is  so  common  in  some  parts  of  the  Continent,  should 
be  avoided,  and  the  clothes  should  be  fastened  by  strings  or  by  sewing, 
and  no  pins  used.  At  the  present  day  it  is  customary  not  to  use  caps, 
so  that  the  head  may  be  kept  cool.  The  utmost  possible  attention 
should  be  paid  to  cleanliness,  and  the  child  should  be  regularly  bathed 
in  tepid  water,  at  iirsTonce  daily,  and  after  the  first  few  weeks  both 
night  and  morning.  After  drying,  the  flexures  of  the  thighs  and  arms 
and  the  nates  should  be  dusted  with  violet  powder  or  fuller^_earth  to 
prevent  chafing  of  the  skin.  The  excreraeiits  should  be  received  in 
napkins  wrapped  round  the  hips,  and  great  care  is  required  to  change 
the  napkins  as  often  as  they  are  wet  or  soiled,  otherwise  troublesome 
irritation  will  arise.  A  neglect  of  this  precaution  and  the  washing  of 
the  naj)kins  with  coarse  soap  or  soda  are  among  the  principal  causes  of 
the  eruptions  and  excoriations  so  common  in  badly-cared-for  children. 
When  washed  and  dressed  the  child  may  be  placed  in  its  cradle  and 
covered  with  soft  blankets  or  an  eider-down  quilt. 

As  soon  as  the  mother  has  rested  a  little  it  is  advisable  to  place  the 
child  to  the  breast.  This  is  useful  to  the  mother  by  favoring  uterine 
contraction.  Even  now  there  is  in  the  breasts  a  variable  quantity  of 
the  peculiar  fluid  known  as  colostrum.     This  is  a  viscid  yellowish  secre- 


MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC.  565 

tion,  different  in  appearance  from  the  thin  bluish  milk  which  is  subse- 
quently formed.  Examined  under  the  microscope,  it  is  found  to  con- 
tain some  milk-globules  and  a  number  of  large  granular  and  small  fat- 
corpuscles.  It  has  a  purgative  property,  and  soon  produces,  with  less 
irritation  than  any  of  theTaxatives  sd"generally  used,  a  discharge  of  the 
meconium  with  which  the  bowels  are  loaded.  Hence  the  accoucheur 
should  prohibit  the  common  practice  of  administering  castor  oil  or  other 
aperient  within  the  first  few  days  after  birth,  although  there  can  be  no 
objection  to  it  in  special  cases  if  the  bowels  appear  to  act  inefficiently 
and  with  difficulty. 

Over-frequent  Suckling-  should  be  Avoided. — For  the  first  few 
days,  and  until  the  secretion  of  milk  is  thoroughly  established,  the  child 
should  be  put  to  the  breast  at  long  intervals  only.  Constant  attempts 
at  suckling  an  empty  breast  lead  to  nothing  but  disappointment,  both  to 
the  mother  and  child,  and  by  unduly  irritating  the  mammge  sometimes 
to  positive  harm.  Therefore,  for  the  first  day  or  two  it  is  sufficient  if 
the  child  be  applied  to  the  breasi^  twice,  or  at  most  three  times,  in  the 
twenty- four  hours.  ?  Nor  is  it  necessary  to  be  apprehensive,  as  many 
mothers  naturally  are,  that  the  child  will  suffer  from  want  of  food.  A 
few  spoonfuls  of  milk  and  water  being  given  from  time  to  time,  the 
child  may  generally  wait  without  injury  until  the  milk  is  secreted.  This 
is  usually  about  the  third  day,  when  the  secretion  is  found  to  be  a 
whitish  fluid,  more  watery  in  appearance  than  cow's  milk,  and  showing 
under  the  microscope  an  abundance  of  minute  spherical  globules  refract- 
ing light  strongly,  which  are  abundant  in  proportion  to  the  quality  of 
the  milk.  A  certain  number  of  granular  corpuscles  may  also  be 
observed  shortly  after  the  birth  of  the  child,  but  after  the  first  month 
these  should  have  almost  altogether  disappeared.  The  reaction  of 
human  milk  is  decidedly  alkaline,  and  the  taste  much  sweeter  than 
that  of  cow's  milk.  ~~" 

/'The  importance  to  the  mother  of  nursing  her  own  child  whenever 
her  health  permits,  on  account  of  the  favorable  influence  of  lactation 
in  promoting  a  proper  involution  of  the  uterus,  has  already  been 
insisted  on.  Unless  there  be  some  positive  contraindication,  such  as 
a  marked  strumous  cachexia,  an  hereditary  phthisical  tendency,  or 
great  general  debility,  it  is  the  duty  of  the  accoucheur  to  urge  the 
mother  to  attempt  lactation,  even  if  it  be  not  carried  on  more  than  a 
month  or  two.  It  is,  however,  the  fact  that  in  the  upper  classes  of 
society  a  large  number  of  patients  are  unable  to  nurse,  even  though 
willing  and  anxious  to  do  so.  In  some  there  is  hardly  any  lacteal 
secretion  at  all ;  in  others  there  is  at  first  an  over-abundance  of  watery 
and  innutritions  milk,  which  floods  the  breasts  and  soon  dies  away 
altogether. 

"When  the  Mother  cannot  Nurse,  a  "Wet-nurse  should  be  Pro- 
cured.— Whenever  the  mother  cannot  or  will  not  nurse  the  question 
Avill  arise  as  to  the  method  of  bringing  up  the  child.  From  many 
causes  there  is  an  increasing  tendency  to  resort  to  bottle-feeding,  instead 
of  procuring  the  services  of  a  wet-nurse,  even  when  the  question  of 
expense  does  not  come  into  consideration.  No  long  experience  is 
required  to  prove  that  hand-feeding  is  a  bad  and  imperfect  substitute 


566  THE  PUERPERAL  STATE. 

for  nature's  mode,  and  one  whicli  the  practitioner  should  discourage 
whenever  it  lies  in  his  power  to  do  so.  It  is  true  that  in  many  cases 
bottle-fed  children  do  well,  but  there  is  good  reason  to  believe  that  even 
when  apparently  most  successful  the  children  are  not  so  strong  in  after 
life  as  they  would  have  been  had  they  been  brought  up  at  the  breast. 
"When,  in  addition,  it  is  borne  in  mind  how  much  of  the  success  of 
hand-feeding  depends  on  intelligent  care  on  the  part  of  the  nurse,  what 
evils  are  apt  to  accrue  from  the  injurious  selection  of  the  food  and  from 
ignorance  of  the  commonest  laws  of  dietetics,  there  is  abundant  reason 
for  urging  the  substitution  of  a  wet-nurse  whenever  the  mother  is 
unable  to  undertake  the  suckling  of  her  child.  It  must  be  admitted 
that  good  hand-feeding  is  better  than  bad  wet-nursing,  and  the  success 
of  the  latter  hinges  on  the  proper  selection  of  a  wet-nurse.  As  this 
falls  within  the  duties  of  the  practitioner,  it  will  be  well  to  point  out 
the  qualities  which  should  be  sought  for  in  a  wet-nurse  before  proceed- 
ing to  discuss  the  mode  of  rearing  the  child  at  the  breast. 

Selection  of  a  "Wet-Nurse. — In  selecting  a  wet-nurse  we  should 
endeavor  to  choose  a  strong,  healthy  woman,  who  should  not  be  over 
thirty  or  thirty-five  years  of  age  at  the  outside,  since  the  quality  of 
the  milk  deteriorates  in  women  who  are  more  advanced  in  life.  For 
a  like  inferiority  a  very  young  woman  of  sixteen  or  seventeen  should 
be  rejected.  It  is  needless  to  say  that  care  must  be  taken  to  ascertain 
the  absence  of  all  traces  of  constitutional  disease,  especially  marks  of 
scrofula  or  enlarged  cervical  or  inguinal  glands,  which  may  possibly  be 
due  to  antecedent  syphilitic  taint.  If  the  nurse  be  of  good  musQular 
development,  healtliy::lqoking,  with  a  clear  complexion,  and  saund 
teeth  (indicating  a  generally  good  state  of  health),  the  color  of  the 
hair  and  eyes  is  of  secondary  importance.  It  is  commonlj'  stated  that 
brunettes  make  better  nurses  than  blondes,  but  this  is  by  no  means 
necessarily  the  case ;  and,  provided  all  the  other  points  be  favorable, 
fairness  of  skin  and  hair  need  be  no  bar  to  the  selection  of  a  nurse. 
The  breasts  should  be  pear-shaped,  rather  firm,  as  indicating  an  abun- 
dance of  gland-tissue,  and  with  the  superficial  veins  well  marked.  Large, 
flabby  breasts  owe  much  of  their  size  to  an  undue  deposit  of  fat,  and 
are  generally  unfavorable.  The  nipple  should  be  prominent,  not  too 
large,  and  free  from  cracks  and  erosions,  which  if  existing  might  lead 
to  subsequent  difficulties  in  nursing.  On  pressing  the  breast  the  milk 
should  flow  from  it  easily  in  a  number  of  small  jets,  and  some  of  it 
should  be  preserved  for  examination.  It  should  be  of  a  bluish- white 
color,  and  when  placed  under  the  microscope  the  field  should  be  covered 
with  an  abundance  of  milk-corpuscles,  and  the  large  granular  corpuscles 
of  the  colostrum  should  have  entirely  disappeared.  If  the  latter  be 
observed  in  any  quantity  in  a  woman  who  has  been  confined  five  or 
six  weeks,  the  inference  is  that  the  milk  is  inferior  in  quality.  It  is 
not  often  that  the  practitioner  has  an  opportunity  of  inquiring  into  the 
moral  qualities  of  the  nurse,  although  much  valuable  information  might 
be  derived  from  a  knowledge  of  her  previous  character.  An  irascible, 
excitable,  or  highly  nervous  woman  will  certainly  make  a  bad  nurse, 
and  the  most  trivial  causes  might  afterward  interfere  with  the  quality 
of  her  milk.     Particular  attention  should  be  paid  to  the  nurseia-Qwu 


MANAGEMENT  OF  THE  INFANT,  LACTATION,   ETC.  567 

child,  since  its  condition  affords  the  best  criterion  of  the  quality  of  her 
milk.  It  should  be  plump,  well-nourished,  and  free  from  all  blemishes. 
If  it  be  at  all  thin  and  wizened,  esj)eciallv  if  there  be  any  snuffling  at 
the  nose,  or  should  any  eruption  exist  affording  the  slightest  suspicion 
of  a  syphilitic  taint,  the  nurse  should  be  unhesitatingly  rejected. 

The  management  of  suckling  is  much  the  same  whether  the  child 
is  nursed  by  the  mother  or  by  a  wet-nurse.  As  soon  as  the  supj^ly  of 
milk  is  sufficiently  established  the  child  must  be  put  to  the  breast  at 
short  intervals,  at_.first  of  about  two  hours,  and  in  about  a  month  or 
six  weeks  of  three^hours.  From  the  lirst  few  days  it  is  a  matter  of 
the  greatest  importance  both  to  the  mother  and  child  to  acquire  regular 
habits  in  this  respect.  If  the  mother  get  into  the  way  of  allowing  the 
infant  to  take  the  breast  whenever  it  cries  as  a  means  of  keeping  it 
quiet,  her  own  health  must  soon  suffer,  to  say  nothing  of  the  discom- 
fort of  being  incessantly  tied  to  the  child's  side ;  while  the  child  itself 
has  not  sufficient  rest  to  digest  its  food,  and  very  shortly  diarrhcea  or 
other  dyspeptic  symptom  is  pretty  sure  to  follow.  After  a  month 
or  two  the  infant  should  be  trained  to  require  the  breast  less  often  at 
night,  so  as  to  enable  the  mother  to  have  an  undisturbed  sleep  of  six 
or  seven^hours.  For  this  purpose  she  should  arrange  the  times  oF 
nursing  so  as  to  give  the  breast  just  before  she  goes  to  bed,  and  not 
again  until  the  early  morning.  If  the  child  should  require  food  in  the 
interval,  a  little  milk  and  water  from  the  bottle  may  be  advantageously 
given. 

The  diet  of  the  nursing  woman  should  be  arranged  on  ordinary 
princi^^les  of  hygiene.  It  should  be  abundant,  simple,  and  nutritious, 
but  all  rich  and  stimulating  articles  ofTbod  should  be  avoid^H".  A 
common  error  in  the  diet  of  wet-nurses  is  over-feeding,  which  con- 
stantly leads  to  deterioration  of  the  milk.  Many  of  these  women 
before  entering  on  their  functions  have  been  living  on  the  simplest 
and  even  sparest  diet,  and  not  uncommonly,  in  the  better  class  of 
houses,  they  are  suddenly  given  heavy  meat  meals  three  and  even  four 
times  a  day,  and  often  three  or  four  glasses  of  stout.  It  is  hardly  a 
matter  of  astonishment  that  under  such  circumstances  their  milk  should 
be  found  to  disagree.  For  a  nursing-woman  in  good  health  two  good 
meat  meals  a  day,  with  two  glasses  of  beer  or  porter,  and  as  mucH"milk 
andnbread-and-butter  as  she  likes  to  take  in  the  intervals,  should  be 
amply  sufficient.  Plenty  of  moderate  exercise  should  be  taken,  and 
the  more  the  nurse  and  child  are  out  in  the  open  air,  provided  the 
weather  be  reasonably  fine,  the  better  it  is  for  both. 

[Usually,  the  wet-nurses  employed  in  our  cities  are  of  foreign  birth ; 
where  they  are  natives,  their  children  are  commonly  illegitimate.  An 
American  nurse  is  in  general  preferable,  and  as  a  rule,  those  making 
application  have  not  been  in  the  habit  of  using  malt  drinks.  A 
healthy  woman  will  usually  nurse  well  on  her  ordinary  diet,  which 
should  be  largely  farinaceous.  Ale  is  often  recommended  to  nursing 
mothers,  and  so  also  is  tea,  but  both  are  very  inferior  toinilk  and 
farinaceous  diets  prepared  with  milk.  Broma  prepared  ^vitJi  cream  I 
have  seen  taken  once  a  day,  for  a  change,  with  advantage. — Ed.] 

Signs  of  Successful  Lactation. — Carried  on  methodically  in  this 


568  THE  rVERPERAL  STATE. 

manner,  wct-nnrsing  .slioukl  give  but  little  troubk-.  In  the  intervals 
between  its  meals  the  ehiltl  sleej)s  most  of  its  time,  and  wakes  with 
retiularity  to  feed;  but  if  the  cliild  be  wakei'ul  and  restless,  orv  ait ei- 
i'eediiiu,  have  disonk'red  bowels,  and,  above  all,  if  it  do  not  piin,  wctk 
by  week,  in  weiolit  (a  ])oiMt  which  should  be  irom  time  to  time  ascer- 
tained by  the  scales),  we  may  conclude  that  there  is  either  some  grave 
defect  in  the  management  of  suckling  or  that  the  milk  is  not  agreeing. 
Sliould  this  unsatisfactory  progress  continue  in  spite  of  our  endeavoi-s 
to  remedy  it,  tliere  is  iio  resource  lei"t  but  the  alteration  of  the  diet, 
either  by  <^"haii^ig_  the  nurse  or  by  bringing  uji  the  child  by  hand. 
The  former  shouluFe  preferred  whenever  it  is  practicable,  and  in  the 
upper  ranks  of  life  it  is  by  no  means  rare  to  have  to  change  the  wet- 
nurse  two  or  three  times  before  one  is  met  with  whose  milk  agrees  per- 
fectly. If  the  child  have  reached  six  or  seven  months  of  age,  it  may 
be  preferable  to  wean  it  altogether,  especially  if  the  mother  have  nursed 
it,  as  hand-feeding  is  much  less  objectionable  if  the  infant  have  had  the 
breast  for  even  a  few  months. 

Period  of  "Weaning". — As  a  rule.  Meaning  should  not  be  attempted 
uiitinieiitition  is  fairly  established,  that  being  the  sign  that  nature  has 
prepared  the  child  for  an  alteration  of  food  ;  and  it  is  better  that  the 
main  portion  of  the  diet  should  be  breast-milk  until  at  least  six  or  seven 
teeth  liave  appeared.  This  is  a  safer  guide  than  any  arbitrary  rule  taken 
from  the  age  of  the  child,  since  the  conuneucement  of  dentition  varies 
much  in  different  cases.  About  the  sixth  or  seventh  month  it  is  a  good 
plan  to  commence  the  use  of  some  suitalSlFartTficiarTood  once  a  day,  so 
as  to  relieve  the  strain  on  the  mother  or  nurse,  and  prepare  the  child  for 
weaning,  M'hich  should  always  be  a  very  gradual  process.  In  this  way 
a  meal  of  rusks  of  entire  wheat-flour,  or  of  bqcf  or  cliickeiijea,  ^s  ith 
bread-crumb  in  it,  maybe  given  AvTtli  advantage;  and  as  the  ])eriod 
for  weaning  arrives  a  second  meal  may  be  added,  and  so  eventually  the 
child  may  be  weaned  without  distress  to  itself  or  trouble  to  the  nurse. 

The  disorders  of  lactation  are  numerous,  and  as  they  frequently 
come  under  the  notice  of  the  practitioner,  it  is  necessary  to  allude  to 
some  of  the  most  common  and    ini])ortant. 

Means  of  Arresting  the  Secietion  of  Milk. — The  advice  of  the 
accoucheur  is  often  required  in  cases  in  which  it  has  been  determined 
that  the  patient  is  not  to  nurse,  M'hen  we  desire  to  get  rid  of  the  milk 
as  soon  as  possible,  or  when  at  the  time  of  weaning  the  same  object  is 
sought.  The  extreme  heat  and  distensicm  of  the  breasts  in  the  former 
class  of  cases  often  gives  rise  to  much  distress.  A  smart  saline  apc'rient 
will  aid  in  removing  the  milk,  and  for  this  purj)0se  a  doi"iT)Tc'"~?eidritx 
])Owder  or  frequent  small  doses  of  sulj)hate  of -magnesia  act  well,  while 
at  tlie  same  time  the  patient  should  be luR'is«no~fake  as  small  a  quan- 
tity of  fluid  as  possible.  Io(yj£,o£^poliissiuni  in  large  doses  of  twenty 
or  twenty-five  grains,  repeated  twice  or  thrice,  has  a  remarkaltle  ettect 
in  arresting  the  secretion  of  milk.  This  observation  was  first  emj)iri- 
cally  inade  by  observing  that  the  secretion  of  milk  was  arrested  when 
this  drug  was  administered  for  some  other  cause;  and  I  have  frequently 
found  it  answer  remarkably  well.  The  distension  of  the  breasts  is  best 
relieved  by  covering  them  w  ith  a  layer  of  lint  or  cotton-wool  soaked  in 


MANAGEMEyT  OF  THE  INFANT,   LACTATION,   ETC.  aGiJ 

a  spirit  lotion  or  can  de  Cologue  and  water,  over  wliieli  oiled  silk  is 
])laeed,  and  by  directinsz;  the  nurse  to  rub  them  gently  with  warm  oil 
whenever  they  get  hard  and  lumpy.  (^  ]5reast-])umps  and  similar  eontri- 
vanees  only  irritate  the  breasts,  and  do„  njore  harm  than  good. ,  The 
loeal  application  of  belladonna  has  been  strongly  recommended  as  a 
means  t()r"jrr(5ventin<>;/Hfecfeal  secretion.  As  usually  applied,  in  the  form 
of  belladonna  plaster,  it  is  likel;^'  to  pi'ove  hurtful,  since  the  breast  often 
enlarges  after  the  plasters  arc  appTrc'TT^'anatne  i)ressure  of  the  unyield- 
ing leather  on  Avhich  they  are  spread  produces  intense  suffering.  A 
better  way  of  using  it  is  by  rubbing  down  a  drachm  of  the  extract  of 
belladonna  with  an  ounce  of  glycerin,  and  applying  this  on  lint.  In 
some  cases  it  answers  extremely  well,  but  it  is  very  uncertain  in  its 
action,  and  frequently  is  quite  useless. 

A  deficiency  of  milk  in  nursing-mothers  is  a  very  common  source 
of  difficulty.  In  a  wet-nurse  this  drawback  is,  of  course,  an  indication 
for  changing  the  nurse ;  but  to  the  mother  the  importance  of  nursing 
is  so  great  that  an  endeavor  must  be  made  either  to  increase  the  flow  of 
milk  or  to  suj:)plement  it  by  other  food.  (Unfortunately,  little  reliance 
can  be  placed  on  any  of  the  so-called  galactagoguesy'  The  only  one 
Avhich  in  recent  times  has  attracted  attention  is  the  leaves  of  the  cni^tor- 
oiTplaiit,  Avliich,  made  into  poultices  and  applied  to  the  breast,  are  said 
to  iiave  a  beneficial  effect  in  increasing  the  flow  of  milk.  More  reliance 
must  be  placed  in  a  sufficiency  of  nutritious  food,  especially  such  as 
contains  phosphatic  elements :  stewed  eels,  oysters,  and  other  kinds  of 
sliell-fish,  and  the  Revalenta  Arabica,  are  recommended  by  Dr.  Routh, 
mIio  has  paid  some  attention  to  this  point,^  as  peculiarly  appropriate. 
If  the  amount  of  milk  be  decidedly  deficient,  the  child  should  be  less 
often  applied  to  the  breast,  so  as  to  allow  milk  to  collect,  and  projierly 
prepared  cow's  milk  from  a  bottle  should  be  given  alternately  with  the 
breast.  This  mixed  diet  generally  answers  well,  and  is  far  preferable 
to  pure  hand-feeding. 

[There  is  no  diet  equivalent  to  milk  for  a  nursing-mother,  where  it 
agrees  with  her.  This  I  have  tested  repeatedly  in  women  who  had 
failed  entirely  in  former  attempts  to  nurse  their  infants.  One  lady  who 
had  lost  her  milk  three  times  at  the  end  of  a  month,  and  had  nursed 
two  babies  into  starvation,  was  enabled  to  nurse  her  fourth  while  on  a 
milk  diet  for  eighteen  months,  and  gained  while  doing  so  nineteen 
pounds.  Another  gained  sixty-five  pounds  -while  nursing,  and  her  son 
was  very  large  for  his  age.  A  third  lost  a  child  by  hand-feeding,  and 
nursed  the  next  infant  on  a  milk  diet,  at  the  same  time  becoming  fatter 
than  she  had  ever  been.  A  decided  advantage  in  the  use  of  milk  is, 
that  it  prevents  the  exhausted  feeling  so  common  with  delicate  nursing 
mothers.  I  have  had  a  patient  of  86  pounds  weight  use  two  quarts  of 
milk  a  day,  and  at  the  same  time  eat  her  usual  measure  of  food,  which 
had  always  been  of  small  amount. — Ed.] 

Depressed  Nipples. — A  not  uncommon  source  of  difficulty  is  a 
<lepressed  condition  of  the  nipples,  which  is  generally  produced  by  the 
constant  pressure  of  the  stays.  The  result  is,  that  the  child,  unable  to 
grasp  the  nipple  and  wearied  with  ineffectual  eftbrts,  may  at  last  refuse 

'  Kouth  on  InJ'ant-jeediwj. 


r>7u  TiiK  ri'icnrKnAL  statk. 

tlic  l)roast  altofrotlicr.  (An  t'lukavor  sliould  Ik*  made  to  clonp^ato  the 
nipple  hetnrc  piittiiii;-  it  into  tlic  cliild's  njontli,  citluT  l)v  the  7rn<:;('rs  or 
hy  sonic  lurni  ol"  hnast-pnnij),  wliidi  liciv  iinds  a  n.-ctnl  aitplit-ation. 
Jn  the  worst  ehiss  of  eases,  when  the  Jiip])k'  is  permanently  (U'j)ress<Hl, 
it  may  be  necessiry  to  let  the  ehild  suek  thron<:,h  a  ghiss  nipple-shiehl, 
to  which  is  attached  an  india-rubber  tube  simihu'  to  that  of  a  suckinir- 
bottle  ;  this  it  is  generally  M'cll  able  to  do. 

Fissures  and  Excoriations  of  the  Nipples. — Fissni-es  and  exco- 
riations of  the  uip])les  are  common  causes  of  sullering,  in  .some  cases 
leading  to  mammary  ab.scess.  Whenever  the  practitioner  has  the  oppor- 
tunity he  .should  advise  his  patient  to  prepare  the  nipple  for  nursing  in 
the  latter  mouths  of  pregnancy;  and  this  may  best  be  done  by  daily 
bathing  it  with  a  s])irituous  or  astringent  lotion,  such  as  eau  de  Cologne 
and  water  or  a  weak  .solution  of  tannin.  After  nursing  has  begun  great 
care  should  be  taken  to  wash  and  dry  the  nij)j)le  after  the  child  has  been 
applied  to  it,  and  as  long  as  the  mother  is  in  the  reciunbent  position  she 
may,  if  the  nipples  be  at  all  tender,  ase  zinc  ni})j)le-.*hields  with  advan- 
tage when  she  is  not  nursing.  In  this  way  these  troublesome  complica- 
tions may  generally  be  prevented.  The  most  common  forms  are  either 
an  abrasion  on  the  surface  of  the  nipple,  which  if  neglected  may  form 
a  small  ulcer,  or  a  crack  at  some  part  of  the  nipjile,  most  generally  at 
its  ba.se.  In  either  case  the  .suffering  Avhen  the  child  is  put  to  the  breast 
is  intense,  .sometimes  indeed  amounting  to  intolerable  anguish,  causing 
the  mother  to  look  forward  with  dread  to  the  application  of  the  chikk 
Whenever  .such  pain  is  complained  of,  the  nipple  should  be  carefully 
examined,  since  the  fissure  or  sore  is  often  .so  minute  as  to  escape  super- 
ficial examination.  The  remedies  recommended  are  vei'v  numerous, 
and  not  always  successful.  Amongst  those  most  conuuonly  u.sed  are 
astringent  applications,  such  as  tannin  or  weak  solutions  of  nitrate  of 
silver,  or  cauterizing  the  edges  oftlie  fissure  with  solid  nitrate  jofsTTyer, 
or  applying  the  flexible  collodion  of  the  Pharmacopa'ia.  Di~AVil.wn 
of  Glasgow  speaks  highl\'~or'a'iotion  comi)osed  of  ten  grains  of  nitrate 
of  lead  in  an  ounce  of  glycerin,  which  is  to  be  applied  after  suckling, 
the  nipple  being  carefully  washed  before  the  child  is  again  put  to  the 
breast,  I  have  my.self  found  nothing  answer  .so  well  as  a  lotion  com- 
posed of  half  an  ounce  of  sulphurous  acid,  half  an  ounce  of  the  gly- 
cerin of  tannin,  and  an  ounce  of  water,  the  beneficial  etfects  of  which 
are  sometimes  quite  remarkable.  Relief  may  occasionally  be  obtained 
by  inducing  the  child  to  suck  through  a  ni])ple-shield,  especially  when 
there  is  only  an  excoriation  ;  but  this  will  not  always  answer,  on  account 
of  the  extreme  pain  which  it  produces. 

Excessive  Flo-w  of  Milk. — An  excessive  flow  of  milk,  known  as 
f/<d(t<-torrhcf(i,  often  interferes  with  successful  lactation.  It  is  by  no 
nieans  rare  in  the  first  weeks  after  delivery  fin-  women  of  delicate  con- 
.stitution,  Avho  are  really  unfit  to  nurse,  to  be  flooded  with  a  superabini- 
dance  of  watery  and  innutritions  milk,  which  .•^(^)on  produces  disordered 
digestion  in  the  child.  (_Under  such  circumstances  the  only  thing  to  l)e 
done  is  to  give  up  an  attempt  which  is  injurious  both  to  the  mother  and 
child.  )  At  a  later  stage  the  milk,  .secreted  in  large  quantities,  is  sufli- 
ciently  nourishing  to  the  child,  but  the  drain  on  the  mother's  con.stitu- 


MANAGEMENT  OF  THE  INFANT,   LACTATION,   ETC.  571 

tion  soon  begins  to  tell  on  her.  Palpation,  jriddiness,  emaciation, 
headache,  loss  of  sleep,  spots  before  the  eyes,  indicatelhe  serions  effects 
which  are  beinji;  j)r()(luced,  and  the  absolute  necessity  of  at  once  stoj)- 
pin*^-  lactation.  Whenever,  tlierefore,  a  nnrsing-wonian  suffers  i'roni 
such  symptoms,  it  is  far  better  at  once  to  remove  the  cause,  otherwise  a 
very  serious  and  permanent  deterioration  of  health  might  result.  When, 
under  such  circumstances,  nursing  is  unwisely  persevered  in,  most  serious 
results  may  follow.  Should  any  diathetic  tendency  exist,  especially  when 
there  is  a  predisposition  to  phtliisis,  nothing  is  so  likely  to  develop  it  as 
the  debility  produced  by  excessive  lactation.  Certain  diseases  of  the 
eye  are  then  specially  apt  to  occur,  such  as  severe  inflannnation  of  the 
cornea,  leading  to  opacity  and  even  sloughing,  and  certain  forms  of 
choroiditis;  also  impairment  of  accommodation  due  to  defective  power 
of  the  ciliary  muscle.^ 

Mammary  Abscess. — There  is  no  more  troublesome  complication 
of  lactation  than  the  formation  of  abscess  in  the  breast — an  occurrence 
by  no  means  rare,  and  which,  if  improperly  treated,  may,  by  long-con- 
tinued suppuration  and  the  formation  of  numerous  sinuses  in  and  about 
the  breast,  produce  very  serious  effects  on  the  general  health.  The 
causes  of  breast  abscesses  are  numerous,  and  very  trivial  circumstances 
may  occasionally  set  up  inflammation  ending  in  suppuration.  Thus  it 
may  follow  exposure  to  cold,  a  blow  or  other  injury  to  the  breast,  some 
temporary  engorgement  of  the  lacteal  tubes,  or  even  sudden  or  depress- 
ing mental,  emotions.  The  most  frequent  cause  is  irritation  from  fissures 
or  erosions  of  the  nipj^les,  which  must  therefore  aR\^ays~Toe"regai*cled 
with  sns])iciou  and  cured  as  soon  as  possible. 

The  abscess  may  form  in  any  part  of  the  breast  or  in  the  areolar  tis- 
sue below  it;  in  the  latter  case  the  inflammation  very  generally  extends 
to'  the  gland-structure.  Abscess  is  usually  ushered  in  by  constitutional  ( 
symptoms,  varying  in  severity  with  the  amount  of  the  inflammation.  I 
Pyrexia  is  always  present,  elevated  ^ei^perature,  rapicLjHilse,  and  much  | 
malaise  and  sense  of  feverishness,  followed  in  many  cases  bv  distinct 
rigor  when  deep-seated  suppuration  is  taking  place.  On  examining  the 
breast  it  will  be  found  to  be  generally  enlai"ged  and  very  tentler,  ^hile 
at  the  site  of  the  abscess  an  indurated  and  painful  sw'elling  may  be  felt. 
If  the  inflammation  be  chiefly  limited  to  the  subglandular  areolar  tis- 
sue, there  may  be  no  localized  swelling  felt,  but  the  whole  breast  will 
be  acutely  sensitive  and  the  slightest  movement  will  cause  much  pain. 
As  the  case  progresses  the  abscess  becomes  more  and  more  superficial, 
the  skin  covering  it  is  red  and  glazed,  and  if  left  to  itself  it  bursts.  In 
the  more  serious  cases  it  is  by  no  means  rare  for  multiple  abscesses  to 
form.  These,  opening  one  after  the  other,  lead  to  the  formation  of 
numerous  fistuknis  tracts,  by  which  the  breast  may  become  completely 
riddled.  Sloughing  of  portions  of  the  gland-tissue  may  take  place,  and 
even  considerable  hemorrhage  from  the  destruction  of  blood-vessels. 
The  general  health  soon  suffers  to  a  marked  degree,  and,  as  the  sinuses 
continue  to  suppurate  for  many  successive  months,  it  is  by  no  means 

'■  See  Foerster  of  Breslau  in  Graefe  and  Snemiseh's  Ilandhnch  des  Gemmmtrn  Ain/en- 
hellkunde,  and  Power  on  "The  Diseases  of  the  Eye  in  Connection  witii  I'regnancy," 
Lancet,  1880,  vol.  i.  p.  709,  el  seq. 


572  THE  rUEIiPERAL  STATE. 

uiu'oiiunon  iur  tlic  patient  to  Ik-  reduced  to  a  state  of  profoiiiid  and  even 
da  I  lo-erous  debi  1  i  t  y. 

Treatment. — Much  may  be  done  by  })roj)er  care  to  ])revcnt  tlie 
formation  of  abscess,  especially  by  reniovinji;  cn<^dr<i'enient  oi' the  lacteal 
ducts,  Mliich  threatened,  by  t;cntle  hand-friction  in  the  nianiicr  already 
indicated.  A\'hen  the  general  symptoms  and  the  local  tenderness  indi- 
cate that  inflammation  has  commenced  we  should  at  once  endeavor  to 
moderate  it,  in  the  ho])e  tliat  resolution  may  occur  Avithout  the  forma- 
tion of  pus.  Here  general  principles  must  be  attended  to,  esi)ecially 
giving  the  affected  ])ai"t  as  much  rest  as  ])Ossible. '^  Feverisliness  may  be 
combated  by  gentle  saHiies,  minute  doses  of  aconite,  and  large  doses  of 
<iui_nine,  Avhile  pain  should  be  relieved  by  opiates.  The  patient  should 
be  strictly  conhned  iii_bcd  and  the  afi'ected  breast  supported  by  a  sus- 
pensory bandage.  ATarnith  and  moisture  are  the  best  means  of  reliev- 
ing the  local  ]M\'m,  either  in  the  form  of  hot  fomentations  or  of  light 
])ouhiccs  of  linseed  meal  or  bread  and  milk,  and  the  breast  may  be 
smeared  vith  extract  of  iK'lladonna  rubbed  do\yn  >vith  glycerin,  or  the 
belladonna  liniment  sprinkled  over  the  surface  of  the  poultices.  The 
local  application  of  ice  in  india-rubber  bags  has  been  highly  extolled 
as  a  means  of  relieving  the  pain  and  tension,  and  is  said  to  be  much 
more  effectual  than  heat  and  moisture.^  Generally,  the  pain  and 
irritation  produced  l^y  putting  the  child  to  the  breast  are  so  great  as  to 
contraindicatc  nursing  from  the  affected  side  altogetlicr,  and  we  must 
trust  to  relieving  the  tension  by  poultices,  suckling  being  in  the  mean 
time  carried  on  by  the  other  breast  alone.  In  favorable  cases  this  is 
quite  possible  for  a  time,  and  it  may  be  that  if  the  inflanimation  do  not 
end  in  suppuration,  or  if  the  abscess  be  small  and  localized,  the  affc-cted 
breast  is  again  able  to  resume  its  functions.  Often  this  is  not  possible, 
and  it  may  be  advisable  in  severe  cases  to  give  uj)  nursing  altogether.' 

The  subsequent  management  of  the  case  consists  in  the  opening  of 
the  abscess  as  soon  as  the  existence  of  pus  is  ascertained,  either  by 
fluctuation,  or,  if  the  site  of  the  abscess  be  deep-seated,  by  the  explor- 
ing-needle.  Mt  maybe  laid  do^vn  as  a  }>rincij)le  that  the  sooner  the  j)us 
is  evacuated  the  better,  and  nothing  is  to  be  gained  by  waiting  until  it 
is  superficial.^  On  the  contrary,  such  delay  only  leads  to  more  exten- 
sive disorganization  of  tissue  and  the  further  spread  of  inflammation. 

The  method  of  opening  the  abscess  is  of  primary  importance. 
It  has  ahyays  been  customary  simply  to  open  the  abscess  at  its  most 
dependent  jiart,  ^\•ithont  using  any  precaution  against  the  admission  of 
air,  and  afterward  to  treat  secondary  abscesses  in  the  same  Avay.  The 
results  are  Avell  kiKnvn  to  all  })ractical  accoucheurs,  and  the  records  of 
surgery  fully  show  how  many  Ayeeks  or  months  generally  elapse  in  bad 
cases  before  recovery  is  complete.  The  antiseptic  trca-tment  of  mam- 
mary abscess  in  the  way  first  jiointcd  out  by  Lister  aifords  results 
"vvhich  are  of  the  most  remarkable  and  satisfactory  kind.  Instead  of 
being  weeks  and  months  in  healing, (^I  believe  that  the  practitioner  who 
fairly  and  minutely  carries  out  Sir  Jose[)h  leister's  directions  may  confi- 
dently look  for  complete  closure  of  the  abscess  in  a  few  days;\ind  I 
know  of  nothing  in  the  whole  range  of  my  professional  experience  that 

^Coi-son,  Avw.  Joimi.  Ohstet.,  1881,  vol.  xiv.  p.  48. 


MANAGEMENT  OF  THE  JNFANT,   LACTATION,   ETC.  573 

has  given  me  more  satisfaction  than  llic  a})plication  of  this  method  ta 
abscesses  of  the  breast.  The  j)lan  I  first  used  is  that  recommended  by 
Lister  in  tlie  Lancet  for  1867,  but  which  is  now  superseded  by  his 
improved  methods,  whicli  of  course  will  be  used  in  pi-eference  by  all 
who  have  made  themselves  familiar  with  the  details  of  antiseptic  sur- 
gery. The  former,  however,  is  easily  within  the  reach  of  every  one, 
and  is  so  simple  that  no  special  skill  or  practice  is  required  in  its  appli- 
cation ;  whereas  the  more  perfected  antiseptic  appliances  will  probably 
not  be  so  readily  obtained  and  are  much  more  difficult  to  use.  I  there- 
fore insert  Sir  Joseph  Lister's  original  directions,  which  he  assures  me 
are  perfectly  antiseptic,  for  the  guidance  of  those  ^vho  may  not  be  able 
to  obtain  the  more  elaborate  dressings  :  "A  solution  of  one  part  of  crys- 
tallized carbolic  acid  in  four  parts  of  boiled  linseed  oil  having  been 
prepared,  a  piece  of  rag  from  four  to  six  inches  square  is  dipped  into 
the  oily  mixture  and  laid  upon  the  skin  where  the  incision  is  to  be 
made.  The  lower  edge  of  the  rag  being  then  raised,  while  the  upper 
edge  is  kept  from  slipping  by  an  assistant,  a  common  scalpel  or  bistoury 
dipped  in  the  oil  is  plunged  into  the  cavity  of  the  abscess,  and  an 
opening  about  three-quarters  of  an  inch  in  length  is  made;  and  the 
instant  the  knife  is  withdrawn  the  rag  is  dropped  upon  the  skin  as  an 
antiseptic  curtain,  beneath  which  the  pus  flows  out  into  a  vessel  placed 
to  receive  it.  The  cavity  of  the  abscess  is  firmly  pressed,  so  as  to  force 
out  all  existing  pus  as  nearly  as  may  be  (the  old  fear  of  doing  mischief 
by  rough  treatment  of  the  pyogenic  membrane  being  quite  ill-fouuded); 
and  if  there  be  much  oozing  of  blood  or  if  there  be  considerable  thick- 
ness of  parts  between  the  abscess  and  the  surface,  a  piece  of  lint  dipped 
in  the  antiseptic  oil  is  introduced  into  the  incision  to  check  bleeding  and 
prevent  primary  adhesion,  which  is  otherwise  very  apt  to  occur.  The 
introduction  of  the  lint  is  effected  as  rapidly  as  may  be,  and  under  the 
protection  of  the  antiseptic  rag.  Thus  the  evacuation  of  the  original 
contents  is  accomplished  with  perfect  security  against  the  introduction 
of  living  germs.  This,  however,  would  be  of  no  avail  unless  an  anti- 
septic dressing  could  be  applied  that  would^  effectually  prevent  the 
decomposition  of  the  stream  of  pus  constantly  flowing  out  beneath  it. 
After  numerous  disappointments  I  have  succeeded  with  the  following, 
which  may  be  relied  upon  as  absolutely  trustworthy:  About  six  tea- 
spoonfuls  of  the  above-mentioned  solution  of  carbolic  acid  in  linseed 
oil  are  mixed  up  with  common  whiting  (carbonate  of  lime)  to  the  con- 
sistence of  a  firm  paste,  which  is,  in  fact,  glazier's  putty  with  the  addi- 
tion of  a  little  carbolic  acid.  This  is  spread  upon  a  piece  of  common 
tinfoil  about  six  inches  square,  so  as  to  form  a  layer  about  a  quarter  of 
an  inch  thick.  The  tinfoil,  thus  spread  with  putty,  is  placed  upon  the 
skin  so  that  the  middle  of  it  corresponds  to  the  position  of  the  incision, 
the  antiseptic  rag  used  in  opening  the  abscess  being  removed  the  instant 
before.  The  tin  is  then  fixed  securely  by  adhesive  plaster,  the  lowest 
edge  being  left  free  for  the  escape  of  the  discharge  into  a  folded  towel 
placed  over  it  and  secured  by  a  bandage.  The  dressing  is  changed,  as 
a  general  rule,  once  in  twenty-four  hours,  but  if  the  abscess  be  a 
very  large  one  it  is  prudent  to  see  the  patient  twelve  hours  after  it 
has  been  opened,  when,  if  the  towel  should  be    much   stained  with. 


574  Till'.  rri:i:i'i:iiM.  state. 

disi'l large,  tlic  tlrL'^siug-  ^;lH)ul^l  be  cliaii<i,Lcl,  tu  avoid  .-«uljjec'ting  its 
antiseptic  virtues  to  too  severe  a  test.  But  after  the  first  twenty- 
four  lioiirs  a  single  daily  dressing  is  sufficient.  The  changing  of  the 
dressing  must  be  nietliodically  tlonc  as  follows:  A  second  similar 
jiiecc  of  tinioil  having  l)ecn  spread  with  the  Jintty,  a  piece  of  rag  is 
di})pcd  in  the  oily  solution  and  i)laccd  on  the  incision  tiie  moment 
the  first  tin  is  removed.  This  guards  against  the  jwssibility  of  mis- 
chief occurring  during  the  cleansing  of  the  skin  with  a  dry  cloth 
and  pressing  out  any  discharge  which  may  exi.st  in  the  cavity.  If  a 
})lug  of  lint  was '  introduced  when  the  abscess  was  opened,  it  is 
removed  under  cover  of  the  antiseptic  rag,  which  is  taken  off  at  the 
moment  wlu'ii  the  new  tin  is  to  be  a|)plied.  The  same  process  is 
continued  daily  until  the  sinus  closes." 

Treatment  of  Long-contin  ;ed  Suppuration. — If  the  ca.se  come 
under  our  care  A\hen  the  abscess  has  been  long  discharging  or  when 
sinuses  have  formed,  the  treatment  is  directed  mainly  to  j)rocuring  a 
cessation  of  suppuration  and  closure  of  the  sinuses.  For  this  purpose 
methodical  strapping  of  the  breast  with  adhesive  plaster,  so  as  to  affi>rd 
steady  supporl"aucl  compress  the  opposing  pyogenic  surfaces,  will  give 
the  best  results.  It  may  be  necessary  to  lay  open  some  of  the  sinu.ses 
or  to  inject  tinct.  iodi  or  other  stimulating  lotions,  so  as  to  moderate  the 
discharge,  the  subsequent  surgical  treatment  varying  according  to  the 
requirements  of  each  case.  In  such  neglected  cases  Bilh'oth  i-ecom- 
mends  that  after  the  ])atient  has  been  aucosthetized  the  openings  should 
Ije  dilated  so  as  to  admit  the  finger,  by  which  the  septa  between  the 
various  sinuses  should  be  broken  down  and  a  large  single  abscess-cavity 
made.  This  sliould  then  be  thoroughly  irrigated  with  a  3  per  cent, 
.solution  of  carbolic  acid,  a  drainage-tube  introduced,  and  the  ordinary 
antiseptic  dressings  a]i])lied.  As  the  drain  on  the  system  is  great  and 
the  constitutional  debility  generally  i)ronounced,  much  attention  nuist 
be  paid  to  general  treatment,  and  abundance  of  nourishing  food,  ajij^ro- 
priate  stimulants,  and  such  medicines  as  iron  and  quinine  Avill  be  indi- 
cated. 

Hand-feeding". — In  a  consideral)le  numl)er  of  cases  the  inability  of 
the  mother  to  nurse  the  child,  her  invincible  re])ugnance  to  a  wet-nur.se, 
or  inability  to  bear  the  expense  renders  hand-feeding  essential.  It  is, 
therefore,  of  importance  that  the  accoucheur  should  be  thoroughly 
familiar  with  the  best  method  of  bringing  up  the  child  by  hand,  .«o  as 
to  be  able  to  direct  the  jn'ocess  in  the  way  that  is  most  likely  to  be 
successful. 

Much  of  the  mortality  following  hand-feeding  may  be  traced  to 
unsuitable  food.  Among  the  ])Oorer  classes  cs[)ccially  there  is  a  ])reva- 
lent  notion  that  milk  alone  is  insufficient,  and  hence  the  almo.st  universal 
custom  of  administering  various  fariuaceous  foods,  such  as  corn-flour  or 
arrowroot,  even  from  tiie  earliest  period.  ^Nlany  of  these  consist  of 
starch  alone,  and  are  therefore  absolutely  unsuited  for  fornung  tlie 
.sta])le  of  diet  on  account  of  the  total  al)sence  of  nitrogenized  elements. 
Independently  of  thisXit  has  been  shown  that  the  saliva  of  infants  has 
not  the  same  digestive  property  on  starch  that  it  sul)sequently  acquires) 
and  this  affords  a  further  explanation  of  its  so  constantly  producing 


MANAGEMENT  OF  TlIK   INFANT,    LA(JTATION,    FTC.  hJPt 

intestinal  (lei'an<^eJiicnt.  iica.s(jii  as  well  as  experience  abundantly 
})rovcs  that  the  object  to  be  aimed  at  iu  liand-feeding  is  to  imitate  as 
nearlv  as  possible  the  food  whicii  nature  .sup])lie,s  for  the  newborn 
f  child/and  therefore  the  obvious  course  i.s  to  use  Jiiilk  from  some  ani- 
mal, so  treated  as  to  make  it  resenibl<'  liumaii  milk  as  nearly  as 
may  bej 

Of  the  various  milks  used,  that  of  the  ass,  on  the  whole,  most  closely 
resembles  human  milk,  containing  less  casein  and  butter  and  more  saline 
ingredients.  It  is  not  always  easy  to  obtain,  and  in  towns  it  is  excess- 
ively expensive.  jNIoreover,  it  does  not  always  agree  with  the  child, 
being  apt  to  produce  diarrhoea.  ^Ve  can,  however,  be  more  certain  of 
its  being  unadulterated,  which  in  large  cities  is  iu  itself  no  small 
advantage,  and  it  may  be  given  without  the  addition  of  water  or 
sugar. 

Goat's  milk  in  England  is  still  more  difficult  to  obtain,  but  it  often 
succeeds  admirably.  In  many  places  the  infant  sucks  the  teat  directly, 
and  certainly  thrives  well  on  this  plan. 

Cow's  Milk,  and  its  Preparation. — In  a  large  majority  of  cases  we 
have  to  rely  on  cow's  milk  alone.  It  differs  from  human  milk  in  con- 
taining less  water,  a  larger  amount  of  casein  and  solid  matters,  and  less 
sugar.  Therefore,  before  being  given  it  requires  to  bejdiluted  and 
sweetened.  A  common  mistake  is  over-dilution,  and  it  is  far  from 
rare  for  nurses  to  administer  one-third  cow's  milk  to  two-thirds  water. 
The  result  of  this  excessive  dilution  is  that  the  child  becomes  pale  and 
puny,  and  has  none  of  the  firm  and  plump  appearance  of  a  well-fed 
infant.  The  practitioner  should  therefore  ascertain  that  this  mistake 
is  not  being  made ;( and  the  necessary  dilution  will  be  best  obtained  by 
adding  to  pure  fresh  cow's  milk  one-third  hot  water,  so  as  to  warm  the 
mixture  to  about  96°,  the  whole  beino;  slightlv  sweetened  with  sugar 
of  milk  or  ordinary  crystallized  sugar.)  ( After  the  first  two  or  three 
months  the  amount  of  water  may  be  lessened,  and  pure  milk,  warmed 
and  sweetened,  given  instead. )  Whenever  it  is  possible  the  milk  should 
be  obtained  from  the  same  cow,  and  in  towns  some  care  is  requisite  to 
see  that  the  animal  is  properly  fed  and  stabled,  Of  late  years  it  has 
been  customary  to  obviate  the  difficulties  of  obtaining  good  fresh  milk 
by  using  some  of  the  tinned  milks  now  so  easily  to  be  had.  These  are 
already  sweetened,  and  sometimes  answer  well  if  not  given  in  too  weak 
a  dilution.  One  great  drawback  in  bottle-feeding  is  the  tendency  of 
the  milk  to  become  acid,  and  hence  to  produce  diarrhoea.  This  may  be 
obviated  to  a  great  extent  by  adding  a  tablespoonful  of  lime-water  to 
each  bottle,  instead  of  an  equal  quantity  of  water. 

Artificial  Human  Milk. — An  admirable  plan  of  treating  cow's  milk, 
so  as  to  reduce  it  to  almost  absolute  chemical  identity  M'ith  human  milk, 
has  been  devised  by  Professor  Frankland,  to  whom  I  am  indebted  for 
])ermission  to  insert  the  recipe.  I  have  followed  this  method  in  many 
cases,  and  find  it  far  superior  to  the  usual  one,  as  it  produces  an  exact 
and  uniform  compound.  "With  a  little  practice  nurses  can  employ  it 
with  no  more  trouble  than  the  ordinary  mixing  of  cow's  milk  with 
water  and  sugar.     The  following  extract  from  I)r.  Frankland 's  w'ork^ 

^  Frankland's  Fxperunental  Besearches  in  Chemistry,  p.  843. 


o76  TllK  PUERPERAL  STATE. 

\\\\\  (.'Xiihiiii  the  iniiiiiplcs  <mi  which  the  ])rc|):ii-ati()ii  of  the  artilicial 
Imiimn  milk  is  Ibuiukcl  :  "  Tlic  rcarin*:- of  iiilants  who  r-aiiiiot  Ik- sup- 
plied with  tlieir  natural  lo(xl  is  notoriously  dillicult  and  uncertain, 
owing  chiefly  to  the  great  diflerenee  in  the  cheniieal  composition  of 
lunnan  milk  and  cow's  milk.  The  latter  is  much  richer  in  casein  and 
poorer  in  milk-sugar  than  the  former,  whilst  a&s's  milk,  which  is  some- 
times used  for  feeiling  infants,  is  too  poor  in  casein  and  butter,  although 
the  proportion  of  sugar  is  nearly  the  same  as  in  human  milk.  The 
relations  of  the  three  kinds  of  milk  to  each  other  are  clearly  seen  from 
the  following  analytical  numbers  which  expres.s  the  percentage  amounts 
of  the  different  constituents : 

Woman.  Ass.  Cow. 

Casein 2.7  1.7  4.2 

Butter 3.5  1.3  3.8 

Milk-sugar 6.0  4.5  3.8 

Salts 2  .5  .7 

These  numbers  show  that  by  the  removal  of  one-third  of  the  ca.seiu 
from  cow's  milk  and  the  addition  of  about  one-third  more  milk-sugar 
a  liquid  is  obtained  which  closely  a])proaches  human  milk  in  composi- 
tion, the  percentage  amounts  of  the  four  chief  constituents  being  as 
follows : 

Casein 2.8 

Butter ...    3.8 

Milk-sugar 5.0 

Salts 7 

Tlie  following  is  the  mode  of  preparing  the  milk  :  Allow  one-third  of 
a  pint  of  new^  milk  to  stand  for  about  twelve  hours,  remove  the  cream, 
and  add  to  it  two-thirds  of  a  pint  of  new  milk,  as  fresh  from  the  cow- 
as  possible.  Into  the  one-third  of  a  \ni\t  of  blue  milk  left  after  the 
abstraction  of  the  cream  put  a  piece  of  rcmiet  about  one  inch  square. 
Set  the  ve-sscl  in  warm  water  until  the  milk  is  fully  cm-died,  an  opera- 
tion requiring  from  five  to  fifteen  minutes  according  to  the  activity  of 
the  rennet,  which  should  be  removed  as  soon  as  the  curding  commences 
and  put  into  an  egg-cup  for  use  on  sub.sequent  occasions,  as  it  may  be 
employed  daily  fora  month  or  two.  Break  up  the  curd  repeatedly  and 
carefully  separate  the  whole  of  the  whey,  which  should  then  be  raj^idly 
heated  to  boiling  in  a  small  tin  pan  placed  over  a  spirit  or  gas  lamp. 
Diu-ing  the  heating  a  further  quantity  of  casein,  technically  called 
*  fleetings,'  separates,  and  must  be  removed  by  straining  through  mus- 
lin. Now  dissolve  110  grains  of  powdered  sugar  of  milk  in  the  hot 
whey,  and  mix  it  with  the  two-thirds  of  a  pint  of  new  milk  to  which 
the  cream  from  the  other  third  of  a  pint  was  added  as  already  described. 
The  artificial  milk  should  be  used  within  twelve  hours  of  its  prepara- 
tion ;  and  it  is  almost  needless  to  add  that  all  the  vessels  employed 
in  its  manufacture  and  administration  should  be  kept  scrupulously 
clean."  1 

^  The  following  recipe  yields  the  same  results,  but  the  method  is  easier,  and  I  find 
that  nurses  prepare  the  milk  with  less  difficulty  when  it  is  followed  :  "Heat  half  a  pint 
of  skimmed  milk  to  about  96°,  that  is,  just  warm,  and  well  stir  into  the  warm  milk  a 


MANAGEMENT  OF  THE  INFANT,   LACTATION,   ETC.  577 

Method  of  Hand-feeding. — Mucli  of  the  succ(,'ss  of  bottle-feeding 
must  depend  on  minute  care  and  scrupulous  cleapiiness,  points  which 
cannot  be  too  strongly  insisted  on.  Particular  attention  should  be  paid 
to  prej2-''^'l'i^^'^?~ii^—  ^' '^'''^  ^*^^*  every  meal,  and  to  keeping  the  feeding 
bottle  and  tuFes  constantly  in  water  when  not  in  use,  so  that  minute 
particles  of  milk  may  not  remain  about  them  and  become  sour.  A 
neglect  of  this  is  one  of  the  most  fertile  sources  of  the  thrush  from 
which  bottle-fed  infants  often  suifer.  The  particular  form  of  bottle 
used  is  not  of  much  consequence.  T  Those  now  commonly  employed,/ 
with  a  long  india-rubber  tube  atta\3hed,  are  preferable  to  the  olden 
forms  of  flat  bottle,  as  they  necessitate  strong  suction  on  the  part  of 
the  infant,  thus  forcing  it  to  swallow  the  food  more  slowly^  Care  must 
be  taken  to  give  the  meals  at  stated  periods_^  as  in  breast-feeding,  and 
these  should  be  at  firsT^out  two  lio'urs  apart,  the  interv^als  being 
gradually  extended.  The  nurse  should  be  strictly  cautioned  against 
the  common  practice  of  placing  the  bottle  beside  the  infant  in  its 
cradle  and  allowing  it  to  suck  to  repletion — a  practice  which  leads  to 
over-distension  of  the  stomach  and  consequent  dyspepsia.  The  child 
should  be  raised  in  the  arms  at  the  proper  time,  have  its  food  adminis- 
tered, and  then  be  replaced  in  the  cradle  to  sleep.  In  the  first  few 
weeks  of  bottle-feeding  constipation  is  very  common,  and  may  be 
effectually  remedied  by  placing  in  the  bottle  two  or  three  times  in  the 
twenty-four  hours  as  much  phosphate  of  soda  as  will  lie  on  a  three- 
penny-piece. '     "^■'■'■•--    

Other  Kinds  of  Food. — If  this  system  succeed,  no  other  food  should 
be  given  until  the  child  is  six  or  seven  months  old,  and  then  some  of 
the  various  infants'  foods  may  be  cautiously  commenced.  Of  these 
there  are  an  immense  number  in  common  use,  some  of  which  are  good 
articles  of  diet,  others  are  unfitted  for  infants.  In  selecting  them  we 
have  to  see  that  they  contain  the  essential  elements  of  nutrition  in 
proper  combination.  All  those,  therefore,  that  are  purely  starchy  in 
character,  such  as  arrowroot,  corn  flour,  and  the  like,  should  be  avoided, 
while  those  that  contain  nitrogenous  as  well  as  starch  elements  may  be 
safely  given.  Of  the  latter  the  entire  wheat-flour,  which  contains  the 
husks  ground  down  with  the  wheat,  generally  answers  admirably ;  and 
of  the  same  character  are  rusks,  tops  and  bottoms,  Nestle's  or  Liebig's 
iofants'  food,  and  many  others.  If  the  child  be  pale  and  flabby,  some 
more  purety  animal  food  may  often  be  given  twice  a  day,  and  great 
benefit  may  be  derived  from  a  single  meal  of  beef-  chicken-  or  veal- 
tea,  with  a  little  bread-crumb  in  it,  especially  after  the  sixth  or  seventh 
month.  Milk,  however,  should  still  form  the  main  article  of  diet,  and 
should  continue  to  do  so  for  many  months. 

Management  -when  Milk  Disagrees. — If  the  child  be  pale,  flabby, 
and  do  not  gain  flesh,  more  especially  if  diarrhoea  or  other  intestinal 
disturbance  be  present,  we   may  be  certain  that  hand-feeding  is  not 

measure  full  of  Walden's  extract  of  rennet.  When  it  is  set,  break  up  the  curd  quite 
small,  and  let  it  stand  for  ten  or  fifteen  minutes,  when  the  curd  will  sink  ;  then  place 
tlie  whey  in  a  saucejian  and  boil  quickly.  When  quite  cold,  add  two-thirds  of  :i  |>int 
of  new  milk  and  two  teaspoonfuls  of  cream,  well  stirrin.o-  the  whole  together.  If  dur- 
ing the  first  month  the  milk  is  too  rich,  use  rather  more  than  a  third  of  a  pint  of  whey." 

37 


57S  77//-;  PrERPERAL  STATE. 

answering  satisfactorily,  1111(1  that  sonic  cliaiit^c'  is  required.  Jltlie  eliild 
be  not  too  old,  and  will  still  take  the  breast,  that  is  certainly  the  best 
remedy,  but  if  that  be  not  possible  it  is  necessary  to  alter  the  diet, 
AVhen  milk  disa^irces,  crj^uni,  in  the  j)roportion  of  one  tai)lcsp()()nful  to 
three  of  water,  soiiietimcs  answers  as  well.  Occasionally  also  Jjiebitr's 
or  Mel bn's^ infants'  food,  when  carefully  jn'cpared,  renders  jj;(Kid  service. 
Too  often,  however,  when  once  diarrluea  oi-  other  intestinal  disturi)ance 
has  set  in,  all  our  efforts  may  prove  unavailin<r,  and  the  health,  if  not 
the  life,  of  the  infant  becomes  seriously  im])erilled.  It  is  not,  however, 
within  the  scope  of  this  work  to  treat  of  the  disordei-s  of  infants  at  the 
breast,  the  proper  consideration  of  which  requires  a  large  amount  of 
space,  and  1  therefore  refrain  from  making  any  further  remarks  on  the 
subject. 


CHAPTER  III. 

PUERPERAL  ECLAMPSIA. 

By  the  term  puerperal  eclampsia  is  meant  a  peculiar  kind  of  epi- 
lejytiform  convulsions  which  may  occur  in  the  latter  months  of  jjreg- 
nancy  or  during  or  after  parturition,  and  it  constitutes  one  of  the  most 
formidable  diseases  with  which  the  obstetrician  has  to  cope.  The 
attack  is  often  so  sudden  and  unexpected,  so  terrible  in  its  nature,  and 
attended  with  such  serious  danger  both  to  the  mother  and  child,  that 
the  disease  has  attracted  much  attention. 

Its  Doubtful  Etiology. — The  researches  of  Lever,  Braun,  Frerichs, 
and  many  other  writers  who  have  shownf  the  frequent  association  of 
eclampsia  with  albuminuria,  have  of  late  years  been  sup])osed  to  clear 
up  to  a  great  extent  the  etiology  of  the  disease  and  to  prove  its  depend- 
ence on  the  retention  of  urinary  elements  in  the  blood.l  While  the 
urinary  origin  of  eclampsia  has  been  pretty  generally  accepted,  mure 
recent  observations  have  tended  to  throw  doubt  on  its  essential  dejiend- 
ence  on  this  cause,  so  that  it  can  hardly  be  said  that  we  are  yet  in  a 
position  to  explain  its  true  pathology  with  certainty.  These  points  will 
re(iuire  separate  discussion,  but  it  is  first  necessary  to  describe  the  cha- 
racter and  history  of  the  attack. 

Considerable  confusion  exists  in  the  description  of  ]Mier|>cral  convul- 
sions from  the  confounding  of  several  essentially  distinct  diseases  under 
the  same  name.  Thus  in  most  obstetric  works  it  has  been  customary 
to  describe  three  distinct  claases  of  convulsion — the  epileptic,  the  Injs-fer- 
icnl,  and  the  apoplectic.  The  two  latter,  however,  come  under  a  totally 
different  category.  A  ])regnant  woman  may  suffer  from  hysterical  [>ar- 
oxysms,  or  she  may  be  attacked  with  apoplexy  accom])anied  with  coma 
and  followed  by  paralysis.     But  these  conditions  in  the  jtregnant  or 


PUERPERAL  ECLAMPSIA.  579 

parturient  woman  arc  identical  with  the  same  diseases  in  the  non-preg- 
uant,  and  are  in  no  way  special  in  their  nature.  True  eclampsia,  how- 
ever, is  different  in  its  clinical  history  from  epilepsy,  althouj^h  tlu;  ])ar- 
oxysms  while  they  last  are  essentially  the  same  as  those  of  an  ordinary 
epileptic  fit. 

Premonitory  Symptoms. — An  attack  of  eclampsia  seldom  occurs 
without  havino-  been  preceded  by  certain  more  or  less  well-marked  pre- 
cursory sym])toms.  It  is  true  that  in  a  considerable  number  of  cases 
these  are  so  slight  as  not  to  attract  attention,  and  suspicion  is  not  aroused 
until  the  patient  is  seized  with  convulsions.  Still,  subsequent  investi- 
oations  will  very  generally  show  that  some  symptoms  did  exist,  w'hich 
if  observed  and  properly  interpreted  might  have  put  the  practitioner 
on  his  guard,  and  possibly  have  enabled  him  to  ward  oif  the  attack. 
Hence  a  knowledge  of  them  is  of  real  practical  value.  The  most  com- 
mon are  associated  with  the  cerebrum,  such  as  severe  headache,  which 
is  the  one  most  generally  observed,  and  is  sometimes  limited  to  one  side 
of  the  head.  Transient  attacks  of  giddiness,  spots  before  theses,  loss 
of  jj^ht,  or  impairmeijt.of  the  iutellecfual  faculties  are  also  not  uncom- 
mon. These  signs  in  a  pregnant  woman  are  of  the  gravest  import,  and 
should  at  once  call  for  investigation  into  the  nature  of  the  case.  Less- 
marked  indications  sometimes  exist  in  the  form  of  irritability,  slight 
headache  or  stupor,  and  a  general  feeling  of  indisposition.  Another 
important  premonitory  sign  is  oedema  of  the  subcutaneous  cellular  tis- 
sue, especially  of  the  face  or  upper  extremities,  which  should  at  once 
lead  to  an  examination  of  the  urine. 

Whether  such  indications  have  preceded  an  attack  or  not,  as  soon  as 
the  convulsion  comes  on  there  can  no  longer  be  any  doubt  as  to  the 
nature  of  the  case.  The  attack  is  generally  sudden  in  its,  onset,  and  in 
its  character  is  precisely  that  of  a  severe  epileptic  fit  or  of  the  convul- 
sions in  children.  Close  observation  shows  that  there  is  at  first  a  short 
period  of  tonic  spasm  affecting  the  entire  muscular  system.  This  is 
almost  immediately  succeeded  by  violent  clonic  contractions,  generally 
commencing  in  the  muscles  of  the  face,  which  twitch  violently  ;  the 
expression  is  horribly  altered,  the  globes  of  the  eyes  are  turned  up  under 
the  eyelids,  so  as  to  leave  only  the  white  sclerotics  visible;  and  the 
angles  of  the  mouth  are  retracted  and  fixed  in  a  convulsive  grin.  The 
tongue  is  at  the  same  time  protruded  forcibly,  and  if  care  be  not  taken 
is  apt  to  be  lacerated  by  the  violent  grinding  of  the  teeth.  The  face, 
at  first  pale,  soon  becomes  livid  and  cyanosed,  while  the  veins  of  the 
neck  are  distended  and  the  carotids  beat  vigorously.  Frothj^  saliva 
collects  about  the  mouth,  and  the  whole  appearance  is  so  changed  as  to 
render  the  patient  quite  mirecognizable.  The  convulsive  movements 
soon  attack  tho.  muscles  of  the  body.  The  hands  and  arms,  at  first  rig- 
idly fixed  with  the  thumbs  clenched  into  the  palms,  begin  to  jerk,  and 
the  whole  muscular  system  is  thrown  into  rapidly-recurring  convulsive 
spasms.  It  is  evident  that  the  in voluntaiT  ,.mug£les  are  implicated  in 
the  convulsive  action  as  well  as  the  voluntary.  This  is  shown  by  a 
temporary  arrest  of  respiration  at  the  commericement  of  the  attack,  fol- 
lowed by  irregular  and  hurried  respiratory  movements  producing  a 
peculiar  hissing  sound.     The  occasional  involuntai-y  expulsion  of  uriue 


580  THE  PUERPERAL  STATE. 

ami  feces  indicates .  ilit'  .suno  I'act.  During;  the  attack  the  patieut  is 
absohitely  unconscious,  sensibility  is  totally  suspended,  and  she  has 
ai'terward  no  recollection  ol'  what  has  taken  ])]ace.  Fortunately,  the 
convulsion  is  not  of  long  duration,  and  at  the  outside  does  not  last  nioi-e 
than  thi'ce  or  ibur  minutes,  generally  not  so  long;  and  it  has  been 
pointed  out  that  a  longer  paroxysm  Mould  almost  uecessiirily  prove  fatal 
on  account  of  the  implication  of  the  respiratory  muscles.  In  most  cases, 
after  an  interval  there  is  a  recurrence  of  the  convulsion  characterized  by 
the  same  phenomena,  and  the  jniroxysms  are  repeated  Avith  more  or  less 
force  and  frequency  according  to  the  severity  of  the  attack.  Sometimes 
several  hours  may  elapse  before  a  second  convulsion  comes  on  ;  at  others 
the  attacks  may  recur  very  often,  -with  only  a  few  minutes  between 
them.  In  the  slighter  forms  of  eclampsia  there  may  not  be  more  than 
two  or  three  paroxysms  in  all ;  in  the  moi'e  serious  as  many  as  Mty  or 
sixty  have  been  recorded. 

Condition  between  the  Attacks. — After  the  first  attack  the  patient 
generally  soon  recovers  her  consciousness,  being  somewhat  dazed  and 
somnolent,  with  no  clear  conception  of  what  has  occurred.  If  the 
paroxysms  be  frequently  repeated,  more  or  less  jDrofound  coma  con- 
tinues in  the  intervals  between  them,  which  no  doubt  depends  upon 
intense  cerebral  congestion,  resulting  from  the  interference  with  the 
circulation  in  the  great  veins  of  the  neck,  produced  by  spasmodic  con- 
traction of  the  muscles.  The  coma  is  rarely  complete,  the  patieut 
showing  signs  of  sensibility  when  irritated,  and  groaning  during  the 
uterine  contractions.  In  the  worst  class  of  cases  the  torpor  may  become 
intense  and  continuous,  and  in  this  state  the  patient  may  die.  When 
the  convulsions  have  entirely  stopped,  and  the  patieut  has  com])letely 
regained  her  consciousness  and  is  apparently  convalescent,  recollection 
of  what  has  taken  place  during  and  some  time  before  the  attack  may 
be  entirely  lost ;  and  this  condition  may  last  for  a  considerable  time. 
A  curious  instance  of  this  once  came  under  my  notice  in  a  lady  who 
had  lost  her  brother,  to  whom  she  w^as  greatly  attached,  in  the  week 
immediately  preceding  her  confinement,  and  in  whom  the  mental  dis- 
tress seemed  to  have  had  a  great  deal  to  do  in  determining  the  attack. 
It  was  many  weeks  before  she  recovered  her  memory,  and  during  that 
time  she  recollected  nothing  about  the  circumstances  connected  with  her 
brother's  death,  the  whole  of  that  w^eek  being,  as  it  were,  blotted  out  of 
her  recollection. 

Relation  of  the  Attacks  to  Labor. — If  the  convulsions  come  on 
during  pregnancy,  we  may  look  upon  the  advent  of  labor  _as  almost  a 
ce^giiit}^;  and,  if  we  consider  the  severe  nervous  shock  and  general 
disturbance,  this  is  the  result  Ave  might  reasonably  anticipate.  If  they 
occur,  as  is  not  uncommon,  for  the  first  time  during  labor,  the  pains 
generally  continue  with  increased_force  and  frequency,  since  the  uterus 
partakes  of  tlie  convulsive  action.  It  has  not  rarely  hajipened  that  the 
pains  have  gone  on  with  such  intensity  that  the  child  has  been  born 
quite  unexpectedly,  the  attention  of  the  practitioner  being  taken  up 
with  the  patient.  In  many  cases  the  advent  of  fresh  paroxysms  is 
associated  with  the  commencement  of  a  pain,  the  irritation  of  which 
seems  sufficient  to  brinsr  on  the  convulsion. 


PUERPERAL  ECLAMPSIA.  581 

Results  to  the  Mother  and  Child. — The  results  of  eclampsia  vary 
accortling-  to  tlie  severity  of  the  paroxysms.  It  is  generally  said  that 
about  \oiie  iu  three  or  four  cases  dies.  [.  The  mortality  has  certainly 
lesseued  of  late  years,  probably  in  conseqfuence  of  improved  knowledge 
of  the  nature  of  the  disease  and  more  rational  modes  of  treatment. 
This  is  well  shown  by  Barker,^  who  found  in  1885  a  mortality  of  32 
per  cent,  in  cases  occurring  before  and  during  labor,  and  22  per  cent, 
in  those  after  labor,  while  since  that  date  the  mortality  has  fallen  to  14 
per  cent.  The  same  conclusion  is  arrived  at  by  Dr.  Phillips,^  who  has 
shown  that  the  mortality  has  greatly  lessened  since  the  practice  of 
repeated  and  indiscriminate  bleeding,  long  considered  the  sheet-anchor 
in  the  disease,  has  been  discontinued  and  the  administration  of  chloro- 
form substituted.  """"       ""      .-——--v. 

Caiise  of  Death. — Death  may  occur  during  the  paroxysm,  and  then 
it  may  be  due  to  the  long  continuance  of  the  tonic  spasm  producing 
asphyxia.  '  It  is  certain  that  as  long  as  the  tonic  spasm  lasts  the  respi- 
rafion  is  suspended,  just  as  iu  the  convulsive  disease  of  children  known 
as  laryngismus  stridulus  ;  and  it  is  possible  also  that  the  heart  may  share. 
in  the  convulsive  contraction  which  is  known  to  aifect  other  involuntary 
muscles.  QVIore  frequently,  death  happens  at  a  later  period  from  the 
combined  effects  of  exhaustion  and  asphyxia. ;  The  records  of  post- 
mortem" exainTMlioiis  are  not  numerous  ;  iu  those  we  possess  the  prin- 
cipal changes  have  been  an  anaemic  condition  of  the  brain  with  some 
cedematous  infiltration.  In  a  few  rare  cases  the  convulsious  have 
resulted  in  effusion  of  blood  into  the  ventricles  or  at  the  base  of  the 
brain.  The  prognosis  as  regards  the  child  is  also  serious.  (Out  of  36 
children.  Hall  Davis  found  26  born  alive,  10  being  stillborn.)  ,'  There 
is  good  reason  to  believe  that  the  convulsion  may  attack  the  child  hi\ 
utero — of  this  several  examples  are  mentioned  by  Cazeaux — or  it  may^ 
be  subsequently  attacked  with  convulsions,  even  when  apparently 
healthy   at   birth. 

Patholog-y, — The  precise  pathology  of  eclampsia  cannot  be  con- 
sidered by  any  means  satisfactorily  settled.  When,  in  the  year  1843, 
Lever  first  showed  that  the_uniie  iu  patients  suffering  from  puerperal 
convulsions  was  generally  ;.highly  charged  with  albumen — a  fact  which 
subsequent  experience  has  amply  confirmed — it  was  thought  that  a  key 
to  the  etiology  of  the  disease  had  been  found.  It  was  known  that 
chronic  forms  of  Bright's  disease  were  frequently  associated  with 
retention  of  urinary  elements  in  the  blood,  and  not  rarely  accom- 
panied by  convulsious.  The  natural  inference  was  drawn  that  the 
convulsions  of  eclampsia  were  also  due  to  toxaemia  resulting  from  the 
retention  of  urea  in  the  blood,  just  as  in  the  urtemia  of  chronic  Bright's 
disease;. and  this  view  was  adopted  and  supported  by  the  authority  of 
Brauu,  Frerichs,  and  many  other  Avriters  of  eminence,  and  was  pretty 
generally  received  as  a  satisfactory  explanation  of  the  facts.  Frerichs 
modified  it  so  far  that  he  held  that  the  true  toxic  element  was  not  urea 
as  such,  but  carbonate  of  ammonia  resulting  from  its  decomposition;  and 
experiments  were  made  to  prove  that  the  injection  of  this  substance  into 
the  veins  of  the  lower  animals  produced  convulsions  of  precisely  the 
'  The  Puerperal  Diseases,  p.  125.  ^  Guy's  Hospital  Reports,  1870. 


582  THE  PUERPERAL  STATE. 

same  character  as  eclampsia.  ^Dr.  llaiiiiaoiul'  of  Maryland  siibsequent- 
\  ly  made  a  series  of  coiintcr-exj)eriraent.s,  whicli  were  held  as  proving 
I  that  there  \va.s  no  reason  to  believe  that  urea  ever  did  become  decom- 
j  posed  in  the  blood  in  the  way  that  Frerichs  supposed,  or  that  the  symp- 
I  tonis  of  uriemia  were  ever  produced  in  this  Avay.  Others  have  believed 
\  that  the  poisonous  elements  retained  in  the  blood  are  not  urea  or  the 
products  of  its  tlecomposition,  but  other  extractive  matters  which  have 
escaped  detection.  xVs  time  elapsed  evidence  accuumlated  to  show  that 
the  relation  between  albuminuria  and  eclampsia  was  not  so  universal 
as  was  supposed,  or  at  least  that  some  other  factors  were  neces'^arv  to 
explain  many  of  the  cases.  Numerous  cases  were  observed  in  Mhich 
albumen  was  detected  in  large  quantities  without  any  convulsion  fol- 
lowing, and  that  not  only  in  women  who  had  been  the  subject  of 
Bright's  disease  before  conception,  but  also  when  the  albuminuria  was 
known  to  have  developed  during  pregnancy.  Thus,  Imbert-Goubeyre 
found  that  out  of  164  cases  of  the  latter  kind,  95  had  no  eclampsia; 
and  Blot,  out  of  41  cases,  found  that  34  were  delivered  without 
untoward  symptoms.  It  may  be  taken  as  proved,  therefore,  that  aliju- 
minuria  is  by  no  means  necessarily  accompanied  by  eclampsia.  Cases 
were  also  observed  in  which  the  albumen  only  appeared  after  the  con- 
vulsion ;  and  in  these  it  was  evident  that  the  retention  of  urinary 
elements  could  not  have  been  the  cause  of  the  attack,  and  it  is  highly 
probable  that  in  them  the  albuminuria  was  produced  l)y  the  same  cause 
which  induced  the  convulsion.  Special  attention  has  been  called  to  this 
class  of  cases  by  Braxton  Hicks,^  who  has  recorded  a  considerable  num- 
ber of  them.  He  says  that  the  nearly  simultaneous  appearance  of  albu- 
minuria and  convulsion — and  it  is  admitted  that  the  two  are  almost  inva- 
riably combined — must  then  be  explained  in  one  of  three  ways  : 

1st.  That  the  convulsions  are  the  cause  of  the  nephritis. 

2dly.  That  the  convulsions  and  the  nephritis  are  produced  by  the 
same  cause — e.  g.  some  detrimental  ingredient  circulating  in  the  blood, 
irritating  both  the  cerebro-spinal  system  and  other  organs  at  the  same 
time. 

3dlv.  That  the  hisrhlv  cono;ested  state  of  the  venous  system  induced 
by  the  spasm  of  the  glottis  in  eclampsia  is  able  to  produce  the  kidney 
com])lication. 

]\Iore  recently,  Tratibe  and  Rosenstein  have  advanced  a  theory  of 
eclampsia  pur})orting  to  explain  the  anomalies.  They  refer  the  occur- 
rence of  eclampsia  to  acute  cerebral  anaemia  resulting  from  changes  in 
the  blood  incident  to  ])regnancy.  The  |>rimary  factor  is  the  hydrjemic 
condition  of  the  blood,  which  is  an  ordinary  concomitant  of  pregnancy, 
and  of  course  when  there  is  also  albuminuria  the  watery  condition  of 
the  blood  is  greatly  intensified  ;  hence  the  frequent  association  of  the 
two  states.  Accompanying  this  condition  of  the  blood  there  is  increased 
tension  of  the  arterial  system,  which  is  favored  by  the  hypertrophy  of 
the  heart  which  is  known  to  be  a  normal  occurrence  in  pregnancy.  The 
result  of  these  combined  states  is  a  temporary  hyperemia  of  the  brain, 
which  is  rapidly  succeeded  by  serous  effusion  into  the  cerebral  tissues, 
resulting  in  pressure  on  its  minute  vessels    and   consequent  anaemia. 

1  Amer.  Joum.  of  Med.  Sci,  1861.  '  Obstet.  Trans.,  1867,  vol.  viii.  p.  382. 


fe 


PUERPERAL  ECLAMPSIA.  583 

There  is  much  in  this  thcury  that  accords  witli  the  most  recent  views  as 
to  the  etiology  of  convulsive  disease;  as,  for  example,  the  researches  of 
Kussmaul  and  Tenner,  who  had  experimentally  proved  the  dependence 
of  convulsion  on  cerel)ral  anaemia,  and  <jf  Brown-Se(juard,  who  showed 
that  an  anaemic  condition  of  the  nerve-centres  preceded  an  e|)ileptic 
attack.  It  explains  also  very  satisfactorily  how  the  occurrence  of  labor 
should  intensify  the  convulsions,  since  during  the  acme  of  the  pains  the 
tension  of  the  cerebral  arterial  system  is  necessarily  greatly  increased. 
There  are,  however,  obvious  difficulties  against  its  general  acceptance. 
For  example,  it  does  not  satisfoctorily  account  for  those  cases  wliich  are 
])receded  by  well-marked  precursory  symptoms,  and  in  which  an 
abundance  of  albumen  is  present  in  the  urine.  Here  the  premonitory 
signs  are  precisely  those  which  precede  the  development  of  ursemia  in 
chronic  Bright's  disease,  the  dependence  of  which  on  the  retention  in 
the  blood  of  urinary  elements  can  hardly  be  doubted.  Moreover,  it 
has  been  shown  by  Lohlein  and  others  that  on  post-mortem  examina- 
tion the  brain  does  not,  as  a  rule,  exhibit  the  oedema,  ansemia,  and  flat- 
tened convolutions  which  this  theory  assumes. 

MacDonald'  has  published  an  interesting  paper  on  this  subject,  in 
which  he  describes  two  very  careful  post-mortem  examinations.  In 
these  he  found  extreme  ansemia  of  the  cerebro-spinal  centres,  with  con- 
gestion of  the  meninges,  but  no  evidence  of  oedema.  He  inclines  to 
the  belief  that  eclampsia  is  caused  by  irritation  of  the  vaso-motor  centre 
in  consequence  of  an  anaemic  condition  of  the  blood  produced  by  the 
retention  in  it  of  excrementitious  matters  which  the  kidneys  ought  to 
have  removed,  this  over-stimulation  resulting  in  anaemia  of  the  deeper- 
seated  nerve-centres  and  consequent  convulsion. 

Excitability  of  Nervous  System  in  Puerperal  "Women  as  Pre- 
disposing- to  Convulsions. — The  key  to  the  liability  of  the  puerperal 
woman  to  convulsive  attacks  is  no  doubt  to  be  found  in  the  peculiar 
/Excitable  condition  of  the  nervous  system  in  pregnaucy-^a  fact  which 
Vas  clearly  pointed  out  by  the  late  Dr.  Tyler  Smith  and  by  many  other 
writers.  Her  nervous  system  is,  in  this  respect,  not  unlike  that  of 
children,  in  whom  the  predominant  influence  and  great  excitability  of 
the  nervous  system  are  well-established  facts,  and  in  whom  precisely 
similar  convulsive  seizures  are  of  common  occurrence  on  the  application 
of  a  sufficiently  exciting  cause. 

Exciting-  Causes. — Admitting  this,  we  require  some  cause  to  set  the 
predisposed  nervous  system  into  morbid  action ;  and  this  we  may  have 
either  in  a  toxoemic  or  in  an  extremely  watery  condition  of  the  blood, 
associated  with  albuminuria,  or  along  with  these,  or  sometimes  inde- 
pendently of  them,  in  some  excitement,  such  as  strong  emotional  dis- 
turbance. It  is  highly  probable,  however,  that  extreme  anaemia  is  one 
of  the  actual  conditions  of  the  nerve-centres — a  fact  of  much  practical 
importance  in  reference  to  treatment. 

Treatment. — The  management  of  cases  in  Avhich  the  occurrence  of 
suspicious  symptoms  has  led  to  the  detection  of  albuminuria  has 
already  been  fully  discussed  (p.  211).     We  shall  therefore  here  only 

^  See  his  volume  of  collected  essays,  entitled  Heart  Disease  during  Preynancy,  Lon- 
don, 1878. 


-^ '.        ^.yiy^ 


584  ^  v^rH  TIW^PUERPERAL  STATE. 


consider  the  treathient  of   cases  in  wiiicli  convnlsions    have    actually 
occurred.  \. 

Until  quite  recently^  venesection  was  regarded  as  the  sheet-anchor 
in  the  treatment,  and  blood  was  always  removed  copiously,  and,  tlici-e 
is  sufficient  reason  to  Ijelicve,  with  occasional  rcmarkabh;  benefit.  Many 
cases  are  recorded  in  which  a  patient  in  a])pai"ently  ])rofound  coma  ra[)- 
idly  regained  her  consciousness  when  blood  was  extracted  in  sufficient 
quantity.  The  improvement,  hoMever,  was  often  transient,  the  convul- 
sions subsequently  recurring  with  increased  vigor.  ^There  are  good  the- 
oretical grounds  for  believing  that  bloodletting  can  only  be  of  merely 
temporary  use,  and  may  even  increase  the  tendency  to  c(jnvuTsTrjnj 
ThescTTre^o  well  i)ut  by  Schroeder  that  I  cannot  do  better  than  quote 
his  observations  on  this  point.  "If,"  lie  says,  "the  theory  of  Traiibe 
and  Rosenstein  be  correct,  a  sudden  depletion  of  the  vascular  system,  by 
which  the  pressure  is  diminished,  must  stop  the  attacks.  From  experi- 
ence it  is  known  that  after  venesection  the  quantity  of  blood  soon  becomes 
the  same  through  the  serum  taken  from  all  the  tissues,  while  the  qual- 
ity is  greatly  deteriorated  by  the  abstraction  of  blood.  A  short  time 
after  venesection  we  shall  expect  to  find  the  former  blood -pressure  in 
the  arterial  system,  but  the  blood  far  more  watery  than  previously. 
From  this  theoretical  consideration  it  follows  that  abstraction  of  blood, 
if  the  above-mentioned  conditions  really  cause  convulsions,  must  be 
attended  by  an  immediate  favorable  result,  and  under  certain  circum- 
stances the  whole  disease  may  surely  be  cut  short  by  it.  But  if  all 
other  conditions  remain  the  same  the  blood-pressure  will  after  some  time 
again  reach  its  former  height.  The  quality  of  blood  has  in  the  mean 
time  been  greatly  deteriorated,  and  consequently  the  danger  of  the  dis- 
ease will  be  increased." 

These  views  sufficiently  well  explain  the  varying  opinions  held  witli 
regard  to  this  remedy,  and  enable  us  to  understand  why,  while  the  effects 
of  venesection  have  been  so  lauded  by  certain  authoi-s,  the  mortality 
has  admittedly  been  much  lessened  since  its  indiscriminate  use  has  been 
abandoned.  It  does  not  follow  because  a  remedy,  when  carried  to 
excess,  is  apt  to  be  hui-tful  that  it  should  be  discarded  altogether; 
and  U.  have  no  doulit  that  in  properly-selected  cases  and  judiciously 
employed  venesection  is  a  valuable  aid  in  the  treatment  of  eelamjisia, 
and  that  it  is  specially  likely  to  be  useful  in  mitigating  the  first  vio- 
lence of  the  attack  and  in  giving  time  for  other  remedies  to  come  into 
action.)  Care  should,  however,  be  taken  to  select  the  cases  jiroperly, 
and  it  will  be  specially  indicated  when  there  is  marked  evidence  of 
gi'cat  cerebral  congestion  and  vascular  tension,  such  as  a  livid  fact',  a 
full  bounding  pulse,  and  strong  pulsation  in  the  carotids.  The  general 
constitution  of  the  patient  may  also  serve  as  a  guide  in  determining  its 
use,  and  we  shall  be  the  more  disposed  to  resort  to  it  if  the  patient  be 
a  strong  and  healthy  woman,  while,  on  the  other  hand,  if  she  be  feeble 
and  Mcak,  we  may  wisely  discard  it  and  trust  entirely  to  other  means. 
In  any  case  it  must  be  looked  upon  as  a  temporary  exi)edient  oidy,  use- 
ful in  warding  off  immediate  danger  to  the  cerebral  tissues,  but  never 
as  the  main  agent  in  treatment.  Nor  can  it  be  permissible  to  bleed  in 
the   heroic   manner  frequently   recommended.     A  single  bleeding,  the 


PUERPERAL  ECLAMPSIA.  585 


> 


'(•^ 


amount  regulated  by  the  effect  produced,  is  all  that  is  ever  likely  U)  1)C       ^ 
of  service.  'j 

As  a  temporary  expedient,  having  the  same  object  iu  view,  compres-  -^^ 
siou  of  the  carotids  during  the  paroxysms  is  worthy  of  trial.  This  was 
jn-oposed  by  Trousseau  in  the  eclampsia  of  infants,  and  in  the  single 
case  of  eclampsia  in  which  I  have  tried  it  it  seemed  to  be  decidedly 
beneticial.  It  is  a  simple  measure,  and  it  offers  the  advantage  of  not 
leading  to  any  permanent  deterioration  of  the  blood,  as  iu  venesection.  ^ 

As  a  subsidiary  means  of  diminishing  vascular  tension  the  adminis- 
tration of  a  strong  purgative  is  desirable,  and  has  the  further  effect  of 
removing  anylrfitant  maTter  that  may  be  lodged  in  the  intestinal  tract. 
If  the  patient  be  conscious,  a  full  dose  of  the  compound  jalap  powder 
may  be  given  or  a  few  grains  of  calomel  combinecTAvTtli  jalap;  and  if 
she  be  comatose  and  unable  to  swa1lT7vr,'a  drop  of  croton  oil  or  a  quar-  |  t  *T 
ter  of  a  grain  of  elaterium  may  be  placed  on  the  back  of  the  tongue.  Lj     ^ 

The  great  indication  in  the  management  of  eclampsia  is  the  control-  /  ( 
ling  of  convulsive  action  by  means  of  sedatives.  Foremost  amongst  O  ^_i 
them  must  be  placed  the  inhalation  of  chloroform,  a  remedy  which  is 
frequently  remarkably  useful,  and  which  has  the  advantage  of  being- 
applicable  at  all  stages  of  the  disease  and  whether  the  patient  be  coma- 
tose or  not.  Theoretical  objections  have  been  raised  against  its  employ- 
ment, as  being  likely  to  increase  cerebral  congestion.  Of  this  there  is 
no  satisfactory  proof;  on  the  contrary,  there  is  reason  to  think  that 
chloroform  inhalation  has  rather  the  effect  of  lessening  arterial  tension, 
while  it  certainly  controls  the  violent  muscular  action  by  which  the 
hypersemia  is  so  much  increased.  Practically,  no  one  who  has  used  it 
can  doubt  its  great  value  in  diminishing  the  force  and  frequency  of  the 
convulsive  paroxysms.  Statistically,  its  usefulness  is  shown  by  Char- 
pentier  in  his  thesis  on  the  effects  of  various  methods  of  treatment  in 
eclampsia,  since  out  of  63  cases  iu  which  it  was  used,  in  48  it  had  the 
effect  of  diminishing  or  arresting  the  attacks,  1  only  proving  fatal. 
The  mode  of  administration  has  varied.  Some  have  ffiven  it  almost  con- 
tiuuously,  keeping  the  patient  in  a  more  or  less  profound  state  of  anaes- 
thesia. Others  have  contented  themselves  with  carefully  Avatching  the 
patient,  and  exhibiting  the  chloroform  as  soon  as  there  were  any  indica- 
tions of  a  recurring  paroxysm,  with  the  view  of  controlling  its  inten- 
sity. The  latter  is  the  plan  I  have  myself  adopted,  and  of  the  value 
of  which  in  most  cases  I  have  no  doubt.  Everv  now  and  again  cases 
will  occur  in  which  chloroform  inhalation  is  insufficient  to  control  the 
paroxysm,  or  in  which,  from  the  very  cyanosed  state  of  the  patient,  its 
administration  seems  contraiudicated.  INIoreover,  it  is  advisable  to 
have,  if  possible,  some  remedy  more  continuous  in  its  action  and 
requiring  less  constant  personal  supervision.  Latterly,  the  internal 
administration  of  chloral  has  been  recommended  for  this  purpose.  My 
own  experience  is  decidedly  in  its  favor,  and  I  have  used,  as  I  believe, 
with  marked  advantage  a  combination  of  chloral  with  bromide  of  potas- 
sium, in  the  proportion  of  twenty  grains  of  the  former  to  half  a  drachm 
of  the  latter,  repeated  at  intervals  of  from  four  to  six  hours.  If  the 
patient  be  unable  to  swallow,  the  chloral  may  be  given  in  an  enema  or 
hypodermically,  six  grains  being  diluted  iu  oj  of  water  and  injected 


586  THE  PUERPERAL  STATE. 

uikIlt  the  skill.  Tlic  rtiiiarknhU'  induciict'  of  hroiiiidr  ot"  pota.-sium  in 
fontrollini^  the  eclampsia  oi"  infants  would  seem  to  be  an  indication  for 
its  use  in  ])Uorperal  cases.  Fortlyce  Baker  is  opposed  to  the  use  of 
chloral,  which  he  thinks  excites  insteatl  of  lesseninir  reflex  irritability.' 
Another  remedy,  not  entirely  free  from  theoretical  objections,  but 
strongly  recommendetl,  is  the  subcutaneous  inject  1^211. of  niorphja,  which 
lias  the  advantage  of  being-  aj)plicable  when  the  ])atient^s  (juite  unable 
to  swallow.  It  may  be  given  in  doses  of  one-third  of  a  grain,  rej)eated 
in  a  few  hours,  so  as  to  keep  the  patient  well  under  its  influence.  It 
is  to  be  remembered  that  the  object  is  to  control  muscular  action,  so  as 
to  prevent  as  much  as  possible  the  violent  convulsive  parttxysm,  and 
therefore  it  is  necessary  that  the  narcosis,  however  ])ro(luced,  should  be 
continuous.  It  is  rational,  therefore,  to  combine  the  intermittent  action 
of  chloroform  -with  the  more  continuous  action  of  other  remedies,  so 
that  the  former  should  supplement  the  latter  when  insufficient.  Inha- 
lation of  the  nitrite  of  amyl  has  been  recommended  on  j)hysiological 
grounds  as  likely  to  be  useful,  and  is  well  worthy  of  trial ;  but  of  its 
action  I  have  as  yet  no  personal  experience.  Several  very  successful 
eases  of  treatment  by  the  inhalation  of  oxygen  have  been  recorded  by 
Schmidt  of  St.  Petersburg.^  Pilocarpine  has  recently  been  tried,  in  the 
hope  that  the  diaphoresis  and  salivation  it  produces  might  diminish 
arterial  tension  and  free  the  blood  of  toxic  matters.  Brauu^  admin- 
istered 3  centigrammes  of  the  muriate  of  pilocarpine  hypodermically, 
and  reports  favorably  of  the  result ;  Fordyce  Barker,^  however,  is  of 
opinion  that  it  produces  so  much  depression  as  to  be  dangerous. 

Other  remedies,  supposed  to  act  in  the  way  of  antidotes  to  ursemic 
poisoning,  have  been  advised,  such  as  acetic  or  benzoic  acid,  but  they 
are  far  too  uncertain  to  have  any  reliance  placed  on  them,  and  they 
distract  attention  from  more  useful  measures. 

Precautions  during  the  Paroxysm. — Precautions  are  necessary 
during  the  fits  to  prevent  the  patient  injuring  herself,  especially  to 
obviate  lacei-ation  of  the  tongue ;  the  latter  can  be  best  done  by 
placing  something  between  the  teeth  as  the  paroxysm  comes  on,  such 
as  the  handle  of  a  teaspoon  enveloped  in  several  folds  of  flannel. 

Obstetric  Management. — The  obstetric  management  of  eclampsia 
will  naturally  give  rise  to  much  anxiety,  and  on  this  point  there  has 
been  considerable  difference  of  opinion.  On  the  one  hand,  we  have 
practitioners  who  advise  the  immediate  emptying  of  the  uterus,  even 
when  labor  has  commenced  ;  on  the  other,  those  who  would  leave  the 
lalior  entirely  alone.  Thus  Gooch  said  :  "  Attend  to  the  convulsions, 
and  leave  the  labor  to  take  care  of  itself;  and  Schroeder  says:  ''  Especi- 
allv  no  kind  of  obstetric  manipulation  is  recpiired  for  the  safety  of  the 
mother,"  but  he  admits,  how^e\'er,  that  it  is  sometimes  advisable  to  hasten 
the  labor  to  ensure  the  safety  of  the  child. 

In  cases  in  which  the  convulsions  come  on  during  labor  the  pains  are 
often  strong  and  regular,  the  labor  progresses  satisfactorily,  and  no  inter- 

'  The  Puerperal  Diseases,  p.  1 20. 

"^London  Med.  Rec,  188G,  vol.  xiv.  p.  75  (extract  from  Rnx.'i/caia  Meditz.,  No.  32,  1885, 
p.  595). 

"^  Berlin,  /din.  Woch.,  June  IG,  1879.  *  New  York  Med.  Rcc,  Mardi  1,  1879. 


PUERPERAL  INSANITY.  587 

ference  is  needful.  In  others  we  cuuiiot  but  feel  that  emptying  the 
uterus  would  be  decidedly  beneficial.  We  have  to  reflect,  however, 
that  any  active  interference  might,  of  itself,  prove  very  irritating  and 
excite  fresh  attacks.  [Eclampsia  is  sometimes  ]iurely  reflex,  and  not 
at  all  dangerous,  although  it  may  be  alarming.  The  convulsive  move- 
ments may  arise  from  nerve-disturbance  due  to  the;  flctal  head  distend- 
ing the  cervix  in  the  last  stage  of  dilatation  in  primipane.  When  the 
head  begins  to  distend  the  perineum  the  convulsive  seizure  often  ceases. 
Such  patients  are  safer  without  the  forceps. — Ed.]  The  influenceof  uterine 
irritation  is  apparent  by  the  frequency  with  which  the  paroxysms  recur 
Avitli  the  pains.  If,  therefore,  the  os  be  undilated  and  labor  have  not 
begun,  no  active  means  to  induce  it  should  be  adoj)ted,  although  the 
membranes  may  be  ruptured  with  advantage,  since  that  procedure  pro- 
duces no  irritation.  Forcible  dilatation  of  the  os,  and  especially  turn- 
ing, are  strongly  contraiudicated. 

The  rule  laid  down  by  Tyler  Smith  seems  that  which  is  most  advisa- 
ble to  follow — that  we  should  adopt  the  course  which  seems  least  likely 
to  ])rove  a  source  of  irritation  to  the  mother.  Thus,  if  the  fits  seem 
evidently  induced  and  kept  up  by  the  pressure  of  the  foetus,  and  the 
head  be  within  reach,  the  forceps  may  be  resorted  to.  But  if,  on  the 
other  hand,  there  be  reason  to  think  that  the  operation  necessary  to 
complete  delivery  is  likely  j^er  se  to  prove  a  greater  source  of  irritation 
than  leaving  the  case  to  nature,  then  we  should  not  interfere. 

[If  called  to  a  case  of  convulsions  followed  by  coma  in  a  primipar;B 
near  term,  but  not  in  labor,  draw  ofl"  a  little  urine  and  examine  it,  as 
the  patient  may  be  far  advanced  in  Bright's  disease  and  the  coma  purely 
urremic.  In  such  a  case  little  can  be  gained  by  bringing  on  labor  and 
delivering  the  foetus. — Ed.] 


CHAPTER   IV. 

PUERPERAL    INSANITY. 

Classification. — Under  the  head  of  "Puerperal  Mania"  writers  on 
obstetrics  have  indiscriminately  classed  all  cases  of  mental  disease  con- 
nected with  pregnancy  and  parturition.  The  result  has  been  unfortu- 
nate, for  the  distinction  between  the  various  types  of  mental  disorder 
has,  in  consequence,  been  very  generally  lost  sight  of.  But  little  study 
of  the  subject  suffices  to  show  that  the  term  "puerperal  mania"  is  wrong 
in  more  ways  than  one,  for  we  find  that  a  large  number  of  cases  are  not 
cases  of  "  mania  "  at  all,  but  of  melani'holia,  while  a  considerable  num- 
ber are  not,  strictly  speaking,  "puerperal,"  as  they  either  come  on  during 


588  THE  PUERPERAL  STATE. 

piegnancv  or  long  after  the  iininediate  risks  of  the  jnierperal  period  are 
over,  beiny;  in  tiie  latter  case  associated  with  aiuernia  produced  i)y  over- 
lactatiou.  For  the  sake  of  brevity,  the  generic  term  "  puerperal  insanity  " 
may  be  employed  to  cover  all  cases  of  mental  disorders  connected  with 
gestation,  which  may  be  further  conveniently  subdivided  into  three 
classes,  each  havinii;  its  special  characteristics,  viz.: 

I.  The  Insanltii  of  Pregnancy. 

II.  Fucrpend  Jiisdjiifi/,  properly  so  called;  that  is,  insanity  coming 
on  within  a  limited  period  after  delivery. 

III.  The  Insanity  of  Lactation. 

This  division  is  a  strictly  natural  one,  and  includes  all  the  cases  likely 
to  come  under  observation.  The  relative  proj)ortion  these  classes  bear 
to  each  other  can  only  be  determined  by  accurate  statistical  observations 
on  a  large  scale,  but  these  materials  we  do  not  possess.  The  returns 
from  large  asylums  are  obviously  open  to  objection,  tor  only  the  M'orst 
and  most  couHrmed  cases  find  their  way  into  these  institutions,  while  by 
far  the  greater  proportion,  both  before  and  after  labor,  are  treated  in 
their  own  homes. 

Proportion  of  these  Porras  of  Insanity. — Taking  such  returns  as 
only  a])proximate,  we  find  from  Dr.  Battv  Tuke  '  that  in  the  Edinburgh 
Asylum,  out  of  155  cases  of  puerperal  insanity,  28  occurred  before 
delivery,  73  during  the  puerperal  period,  and  54  during  lactation.  The 
relative  proportions  of  each  per  hundred  are  as  follows : 

Insanity  of  pregnancy,  18.06  per  cent. 
Puerperal  insanity,         47.09        " 
Insanity  of  lactation,     34.83        " 

Marc4  ^  collects  together  several  series  of  cases  from  various  authorities, 
amounting  to  310  in  all,  and  the  results  are  not  very  different  from 
those  of  the  Edinburgh  Asylum,  except  in  the  relatively  smaller  num- 
ber of  cases  occurring  before  delivery.  The  percentage  is  calculated 
from  his  figures : 

Insanity  of  pregnancy,    8.06  per  cent. 
Puerperal  insanity,         58.06        " 
Insanity  of  lactation,     30.30        " 

As  each  of  these  classes  differs  in  various  important  respects  from  the 
others,  it  Avill  be  better  to  consider  each  separately. 

The  insanity  of  pregnancy  is,  Mithout  doubt,  the  least  common  of 
the  three  forms.  The  intense  mental  depression  which  in  many  women 
accompanies  pregnancy,  and  causes  the  })atient  to  take  a  despondent 
view  of  her  condition  and  to  look  forward  to  the  result  of  her  labor 
with  the  most  gloomy  apprehension,  seems  to  be  often  only  a  lesser 
degree  of  the  actual  mental  derangement  which  is  occasionally  met 
with.  The  relation  between  the  two  states  is  further  borne  out  by  the 
fact  that  a  large  majority  of  cases  of  insanity  during  pregnancy  are 
well-marked  types  of  melancholia :  out  of  28  cases  recorded  by  Tuke, 
15  were  examples  of  jmre  melancholia,  5  of  dementia  with  melancholia. 
In  many  of  the.se  the  attack  could  be  traced  as  developing  itself  out  of 

'  Edin.  Med.  Journ.,  vol.  x.  '  Traite  de  la  Folic  des  Femmes  enceintes. 


PUERPERAL  INSANfTY.  589 

the  ordimiiy  hypoehoiidriasis  of  pregnancy.  In  others  the  symptoms 
come  on  at  a  later  jwriod  of  pregnancy,  the  earlier  months  of  which 
had  not  been  marked  by  any  nnusual  lowness  of  spirits.  The  age  of 
the  patient  seems  to  have  some  influence,  the  proportion  of  cases  between 
thirty  and  forty  years  of  age  being  much  larger  than  in  younger 
women.  A  larger  proportion  of  cases  occurs  in  primipara)  than  in 
multiparie — a  fact  that  no  doubt  depends  on  the  greater  dread  and 
ai)[)reliension  experienced  by  women  who  are  pregnant  for  the  first  time, 
es[)ecially  if  not  very  young.  Hereditaiy  disposition  plays  an  import- 
ant part,  as  in  all  forms  of  puerperal  insanity.  It  is  not  always  easy 
to  ascertain  the  fact  of  an  hereditary  taint,  since  it  is  often  studiously 
concealed  by  the  friends.  Tuke,  however,  found  distinct  evidence  of  it 
in  no  less  than  12  out  of  28  cases.  Furstner  ^  believes  that  other  neur- 
oses have  an  important  influence  in  the  causation  of  the  disease.  Out 
of  32  cases  he  found  direct  hereditary  taint  in  9,  but  in  11  more  there 
was  a  family  history  of  epilepsy,  drunkenness,  or  hysteria. 

Period  of  Pregnancy  at  which  it  Occurs. — The  period  of  preg- 
nancy at  which  mental  derangement  most  commonly  shows  itself  varies. 
Most  generally,  perhaps,  it  is  at  the  end  of  the  third  or  the  beginning 
of  the  fourth  month.  It  may,  however,  begin  with  conception,  and 
even  refiirh  with  every  impregnation.  Montgomery  relates  an  instance 
in  which  it  recurred  in  three  successive  pregnancies.  Marce  distin- 
guishes between  true  insanity  coming  on  during  pregnancy  and  aggra- 
vated hypochondriasis,  by  the  fact  that  the  latter  usually  lessens  after 
the  third  month,  while  the  former  most  commonly  begins  after  that 
date.  It  is  unquestionable  that  in  many  cases  no  such  di'stiuction  can 
be  made,  and  that  the  two  are  often  very  intimately  associated. 

The  form  of  insanity  does  not  differ  from  ordinary  nielancholia. 
The  suicidal  tendency  is  generally  very  strongly  developed.  Should 
the  mental  disorder  continue  after  delivery,  the  patient  may  very  prob- 
ably experience  a  strong  impulse  to  kill  her  child.  Moral  perversions 
have  not  been  uncommonly  observed.  Tuke  especially  mentions  a 
tendency  to  dipsomania  in  the  early  months,  even  in  women  who  have 
not  shovv^n  any  disposition  to  excess  at  other  times.  He  suggests  that 
this  may  be  an  exaggeration  of  the  depraved  appetite  or  morbid  crav- 
ing so  commonly  observed  in  pregnant  wbliien,  just  as  melancholia  may 
be  a  farther  development  of  lowness  of  spirits.  Laycock  mentions  a 
disposition  to  "  kleptmiiania "  as  very  characteristic  of  the  disease. 
'Casper^  relates  a  curious  case  where  this  occurred  in  a  pregnant  lady  of 
rank,  and  the  influence  of  pregnancy  in  developing  an  irresistible  tend- 
ency was  pleaded  in  a  criminal  trial  in  which  one  of  her  petty  thefts 
had  involved  her.  .^ 

Prognosis. — The  prognosis  may  be  said  to  be,  on  the  whole,  favor- 
able. Out  of  Dr.  Tuke's  28  cases,  19  recovered  within  six  months. 
There  is  little  hope  of  a  cure  until  after  the  termination  of  the  jn-eg- 
nancy,  as  out  of  19  cases  recorded  by  Marce  only  in  2  did  the  insanity 
disappear  before  delivery. 

Transient  Mania  during  Delivery. — There  is  a  peculiar  form  of 

'  Archiv  fur  Psychiatrie,  Band  v.  Heft  2. 

'  Casper's  Forensic  Medicine,  New  Syd.  Soc,  vol.  iv.  p.  308. 


r)9()  THE  rVERPKRAL  STATE. 

mental  derangenicnt  sometiiiies  observt-d  (liiriii!;-  laboiMvliich  is  l)y  sdiiu' 
talked  of  as  a  teni|H)raiy  iiii^anity.  It  may  ]»(_'rliai)s  bo  more  accurately 
described  as  a  kind  of  acute  (liHrium,  produced  in  the  latter  stage  of 
labor  by  the  intensity  of  TlTe'siiiferTng  caused  by  the  pains.  According 
to  Montgomery,  it  is  most  aj)t  to  occur  as  the  head  is  passing  througli 
the  OS  uteri,  or  at  a  later  period  during  the  ex])ulsion  of  the  child.  It 
may  consist  of  merely  a  loss  of  control  over  the  mind,  during  which 
the  patient,  unless  carefully  watched,  might  in  her  agony  seriously 
injure  herself  or  her  child.  Sometimes  it  produces  actual  hallucina- 
tion, as  in  the  case  described  by  Tarnier  in  which  the  patient  fancie<l 
she  saw  a  spectre  standing  at  the  foot  of  her  bed  which  she  made  vio- 
lent efforts  to  drive  away.  This  kind  of  mania,  if  it  may  be  so  called, 
is  merely  transitory  in  its  character,  and  disappears  as  soon  as  the  labor 
is  over.  From  a  medico-legal  point  of  view  it  may  be  of  importance, 
as  it  has  been  held  by  some  that  in  certain  cases  of  infanticide  the 
mother  has  destroyed  the  child  when  iu  this  state  of  transient  frenzy 
and  when  she  was  irresponsible  for  her  acts.  In  the  treatment  of  this 
variety  of  delirium  we  must  of  course  try  to  lessen  the  intensity  of  the 
sutferinir,  and  it  is  in  such  cases  that  chloroform  will  find  one  of  its 
most  valuable  applications. 

True  puerperal  insanity  has  alw^ays  attracted  much  attention  from 
obstetricians,  often  to  the  exclusion  of  other  forms  of  mental  disturbance 
connected  with  the  puerperal  state.  We  may  define  it  to  be  that  form 
of  insanity  which  comes  onfw^ithiu  a  limited  period  after  delivery) and 
which  is  probably  intimately  connected  with  that  process.  Out  of  73 
examples  of  the  disease  tabulated  by  Dr.  Tuke,  only  2  came  on  later 
than  a  month  after  delivery,  and  iu  these  there  were  other  causes  pres- 
ent ;  which  might  possibly  remove  them  from  this  class. 

Although  a  large  number  of  these  cases  assume  the  character  of  acute 
mania,  that  is^bv  uomeaus  the  only  kind  of  insanity  which  is  observecl, 
a  not  inconsiderable  number  being  well-marked  examples  of  melancho- 
lia. )  The  distinction  between  them  was  long  ago  pointed  out  by  (jooch, 
wlfose  admirable  monograph  on  the  disease  contains  one  of  the  most 
graphic  and  accurate  accounts  of  puerperal  insanity  that  has  yet  been 
written. 

There  are  also  some  peculiarities  as  to  the  period  at  which  these  varie- 
ties of  insanity  show  themselves,  which,  taken  in  connection  with  cer- 
tain facts  in  their  etiology,  may  eventually  justify  us  in  drawing  a 
stronger  line  of  demarcation  between  them  than  has  been  usual.  It 
appears  that  cases  of  acute  mania  are  apt  to  come  on  at  a  period  much 
nearer  delivery  than  melancholia.  (Thus,  Tuke  found  that  all  the  cases 
of  mania  came  on  within  sixteen  days  after  delivery,  and  that  all  cases 
of  melancholia  develojied  themselves  after  that  ])eriod.\  We  shall  pres- 
ently see  that  one  of  the  most  recent  theories  as  to  thor  causation  of  the 
disease  attributes  it  to  some  morbid  condition  of  the  blood.  Should 
further  investigation  confirm  this  supposition,  inasmuch  as  sejitic  con- 
ditions of  the  blood  are  most  likely  to  occur  a  short  time  after  labor,  it 
would  not  be  an  improbable  hypothesis  that  cases  of  acute  mania  occur- 
ring within  a  short  time  after  labor  may  depend  on  such  septic  causes, 
while  melancholia  is  more  likely  to  arise  from  general  conditions  favor- 


PUERPERAL  INSANITY.  591 

ing    the   development    of   mental    disease.      This    must,    however,    he 
regarded  as  a  mere  sj)e('ulati(»n,  re(|uiring    I'lirther  investigation. 

Causes. — Hereditary  ])redis])Osition  is  very  frequently  met  with,  and 
a  careful  inquiry  iuto  the  patient's  history  will  gencjrally  show  that 
(»thcr  members  of  tlie  family  have  suffered  from  mental  derangement. 
Reid  found  that  out  of  111  cases  in  Bethlehem  Hospital,  there  was 
clear  evidence  of  hereditary  taint  in  45.  Tuke  made  the  same  observa- 
tion in  22  out  of  his  7o  cases;  and  indeed  it  is  pretty  generally  admit- 
ted by  all  alienist  physicians  that  hereditary  tendencies  form  one  of  the 
strongest  predisposing  causes  of  mental  disturbance  in  the  puerperal 
state,  (in  a  large  proportion  of  cases  circumstances  j)ro(lucing  debility 
xliaustioi 


and  exliiiugtion  or  mental  depression  have  preceded"  tlie  attack.)  Thus 
it  is  often  found  tiiat  palEieuts  attacked  with  it  have  had  post-partum 
hemorrhage  or  have  suffered  from  some  other  conditions  i)roducing 
exhaustion,  such  as  severe  and  complicated  labor,  or  they  may  have 
l)een  weakened  by  over-frequent  pregnancies  or  by  lactation  during 
the  early  mouths  of  pregnancy.  Indeed,  ameraia  is  always  well  marked 
in  this  disease.  Mental  conditions  also  are  frequently  traceable  in  con- 
neetion  with  its  production.  Morbid  dread  during  pregnancy,  insuiB- 
cient  to  produce  insanity  before  delivery,  may  develop  into  mental 
derangement  after  it.  Shame  and  fear  of  exposure  in  unmarried 
M'omen  not  unfrequeutly  lead  to  it,  as  is  evidenced  by  the  fact  that 
out  of  2281  cases  gathered  from  the  reports  of  various  asylums,  above 
64  per  cent,  were  unmarried.^  Sudden  moral  shocks  or  vivid  mental 
impressions  may  be  the  determining  cause  in  predisposed  persons. 
Gooch  narrates  an  example  of  this  in  a  lady  who  was  attacked  imme- 
<1  lately  after  a  fright  produced  by  a  fire  close  to  her  house,  the  hallu- 
cinations in  this  case  being  all  connected  with  light;  and  Tyler  Smith 
that  of  another  whose  illness  dated  from  the  sudden  death  of  a  relative. 
The  a^  of  the  patient  has  .some  influence,  and  there  seems  to  be  a 
decidedly  greater  liability  at  advanced  ages,  especially  when  such  women 
are  pregnant  for  the  first  time. 

The  possibility  of  the  acute  form  of  puerperal  insanity  coming  on 
shortly  after  delivery  being  dependent  on  some  form  of  septicaemia  is 
one  which  deserves  careful  consideration.  The  idea  originated  with 
Sir  James  Simpson,  who  found  albumen  in  the  urine  of  four  patients. 
He  suggested  that  this  might  probably  indicate  the  presence  in  the 
blood  of  certain  urinary  constituents  ^\•llich  might  have  determined 
the  attack  much  in  the  same  -way  as  in  eclampsia.  Dr.  Donkin  subse- 
quently wrote  an  important  paper,^  in  which  he  warmly  supported  thisi 
theory,  and  arrived  at  the  conclusion  "  that  the  acute  dangerous  class  of  ! 
cases  are  examples  of  uru'inic  blood-poisoning,  of  which  the  mania,  rapid 
pulse,  and  other  constitutional  symptoms  are  merely  the  ])henomena, 
and  that  the  affection  therefore  ought  to  be  termed  urajmic  or  renal 
puerperal  mania,  in  contradistinction  to  the  other  form  of  disease."  He 
also  suggests  that  the  immediate  poison  may  be  carbonate  of  ammonia, 
resulting  from  the  decomposition  of  urea  retained  in  the  blood.  It  will 
be  observed,  therefore,  that  i\\Q  pathological  condition  producing  puer- 
peral mania  would,  supposing  this  theory  to  be  correct,  be  precisely  the 

'  Jonrn.  of  Mental  Science,  1870-71,  p.  159.  ^  Edin.  Med.  Journ.,  vol.  vii. 


592  TIIK  PUERPERAL  STATE. 

same  as  that  which  at  other  times  is  suj)pose(I  to  give  rise  to  puerperal 
echuiii)sia.  There  can  be  no  douht  that  {\w  ])atient  immediately  after 
delivery  isin  a  eonditioii  renderii)}^  her  pccuiiai-ly  liable  to  various  forms 
of  sc'ptie  disease;  and  it  must  be  admitted  that  there  is  no  inherent 
improbability  in  the  supposition  that  some  morbid  material  circulating 
in  the  blood  may  be  the  effective  cause  of  the  attack  in  a  person  other- 
wise predisposed  to  it.  It  is  also  certain,  as  I  have  already  ])ointed  out, 
that  there  are  two  distinct  classes  of  cases,  differing  according  to  the 
period  after  delivery  at  which  the  attack  comes  on.  \\'hether  this 
difference  depends  on  the  presence  in  the  blood  of  some  septic  matter 
— especially  urinary  excreta — is  a  question  which  our  knowledge  by 
no  means  justifies  us  in  answering;  it  is,  however,  one  which  well 
merits  further  careful   study. 

^"^It  is  only  fair  to  point  out  some  difficulties  which  appear  to  militate 
against  the  view  M'hich  Dr.  Donkin  maintains.  In  the  first  place,  the 
albuminuria  is  merely  transient,  while  its  supposed  effects  last  for  weeks 
or  months.    Sir  James  Simpson  says,  with  regard  to  his  cases :  "  I  have 

I  seen  all  cases  of  albuminuria  in  puerperal  insanity  disapjjear  from  the 
urine  within  fifty  hours  of  the  access  of  the  malady.  The  general 
rapidity  of  its  disappearance  is  perhaps  the  principal,  or  indeed  the 
only,  reason  Avhy  this  complication  has  escai)ed  the  notice  of  those 
physicians  among  us  who  devote  themselves  with  such  ardor  and  zeal 
to  the  treatment  of  insanity  in  our  public  asylums."  This  apparent 
anomaly  Simpson  attempts  to  explain  by  the  hypothesis  that  when 
once  the  ursemic  poisoning  has  done  its  work  and  set  the  disease  in 
progress  the  mania  progresses  of  itself.  This,  however,  is  ]>ure  specu- 
lation, and  in  the  supposed  analogous  case  of  eclampsia  the  all)uminuria 
certainly  lasts  as  long  as  its  effects.  It  is  not  easy  to  understand  also 
why  ursemic  poisoning  should  in  one  case  give  rise  to  insanity,  and  in 
another  to  convulsions.  For  all  we  know  to  the  contrary,  transient 
albuminuria  may  be  much  more  common  after  delivery  than  has  been 
generally  supposed,  and  further  investigation  on  this  point  is  required. 
Albumen  is  by  no  means  unfrequently  observed  in  the  urine  for  a  short 
time  in  various  conditions  of  the  body,  without  any  serious  consequences, 
as,  for  example,  after  bathing ;  and  we  may  too  readily  draw  an  imjusti- 
fiable  conclusion  from  its  detection  in  a  few  cases  of  mania.  There  are, 
however,  many  other  kinds  of  blood-poisoning  besides  ura?mia  which 
may  have  an  influence  in  the  production  of  the  disease,  and  it  is  to  be 
hoped  that  future  observations  may  enable  us  to  speak  with  more  cer- 
tainty on  this  ])oint. 

The  progTiosis  of  puerperal  insanity  is  a  jwint  which  will  always 
dee])ly  interest  those  who  have  to  deal  with  so  distressing  a  malady.  It 
may  resolve  itself  into  a  consideration  of  the  immediate  risk  to  life  and 
of  the  chances  of  ultimate  restoration  of  the  mental  faculties.  It  is  an 
old  a])horism  of  Gooch's — and  one  the  correctness  of  which  is  justi- 
fied by  modern  experience — that/"  mania  is  more  dangerous  to  life, 
melancholia  to  reason.V  It  has  veiy  generally  been  supposed  that  the 
inniiccliate  risk  to  life  m  puerperal  mania  is  not  great,  and  on  the  whole 
this  may  be  taken  as  correct.  Tuke  found  that  death  took  ])lace  from 
all  causes  in  10.9  per  cent,  of  the  cases  under  observation ;  these,  how- 


PUERPERAL  INSANITY.  593 

ever,  were  all  women  who  had  been  admitted  into  asylums,  and  in  wlium 
tiie  attack  may  be  assumed  to  have  been  exceptionally  severe.  Great 
stress  was  laid  by  Hunter  and  Gooch  on  extreme  ra])idity  of  the  pulse 
as  indicating  a  fatal  tendency.  There  can  be  no  doubt  that  it  is  a  symp- 
tom of  great  gravity,  but  by  no  means  one  wliich  need  lead  us  to  despair 
of  our  ])atient's  recovery.  The  most  dangerous  class  of  cases  are  those 
attended  with  some  inflannuatory  complication  ;  and  if  there  be  marked 
elevation  of  temperature,  indicating  the  presence  of  some  such  concom- 
itant state,  our  prognosis  must  be  more  grave  than  when  there  is  mere 
excitement  of  the   circulation. 

Post-mortem  Signs. — There  are  no  marked  post-mortem  signs 
found  in  fatal  cases  to  guide  us  in  formiirg~air*opTriiori  as  To  the  nature 
of  the  disease.  "  No  constant  morbid  changes,"  says  Tyler  Smith, 
"  are  found  within  the  head,  and  most  frequently  the  only  condition 
found  in  the  brain  is  that  of  unusual  paleness  and  exsanguinity. 
Many  pathologists  have  also  remarked  upon  the  extremely  empty 
condition  of  the  blood-vessels,  particularly  the  veins." 

The  duration  of  the  disease  varies  considerably.  Generally  speak-  S 
ing,  cases  of  mania  do  not  last  so  long  as  melancholia,  and  recovery  ( 
takes  place  within  a  period  of  three  months,  often  earlier.  Very  few 
of  the  cases  admitted  into  the  Edinburgh  Asylum  remained  there  more 
than  six^jQianths,  and  after  that  time  the  chances  of  ultimate  recoveiy 
greatly  lessened.  When  the  patient  gets  well  it  often  happens  that  her 
recollection  of  the  events  occurring  during  her  illness  is  lost ;  at  other 
times  the  delusions  from  which  she  suffered  remain,  as,  for  example,  in 
a  case  which  was  under  my  care  in  which  the  personal  antipathies  which 
the  patient  formed  when  insane  became  permanently  established. 

Insanity  of  Lactation. — 54  out  of  the  155  cases  collected  by  Dr. 
Tuke  were  examples  of  the  insanity  of  lactation,  which  would  appear, 
therefore,  to  be  nearly  twice  as  common  as  that  of  pregnancy,  but  con- 
siderably less  so  than  the  true  puerperal  form.  fl!ts  dependence  ou 
causes  producing  ansemia  and  exhaustion  is  obvious  and  well  markedA 
In  the  large  maiority  of  cases  it  occurs  in  multiparse  who  have  been 
debilitated  by  frequent  jDregnancies  and  by  length  of  nursing.  When 
occurring  in  primiparse,  it  is  generally  in  Avomen  who  have  suffered 
from  post-partum  hemorrhage  or  other  causes  of  exhaustion,  or  whose 
constitution  was  such  as  should  have  contraindicated  any  attempt  at 
lactation.  The  bruit  de  diable  is  almost  invariably  present  in  the  veins 
of  the  neck,  indicating  the  impoverished  condition  of  the  blood. 

The  type  is  far  more  frequently  melancholic  than  maniacal,  and  when 
the  latter  form  occurs  the  attack  is  much  mQre_„tiailsient  than  in  true 
puerperal  insanity,  y  The  danger  to  life  is  not  great,  especially  if  the  \\ 
cause  producing  debility  be  recognized  and  at  once  removed. '  ' 

There  seems,  however,  to  be  more  risk  of  the  insanity  becoming  per- 
manent than  in  the  other  forms.  In  12  out  of  Dr.  Tuke's  cases  the 
melancholia  degenerated  into  dementia  and  the  patients  became  hope--- 
lessly  insane. 

Symptoms. — The  symptoms  of  these  various  forms  of  insanity  are 
practically  the  same  as  in  the  non-pregnant  state. 

Generally  in  cases  of  mania  there  is  more  or  less  premonitory  iudica- 


594  Tin-:  PUERPERAL  STATE. 

tion  of  mental  (listurbance,  wliicli  may  pass  iin|K'rceivo<l.  'I'lic  attack 
is  often  })rc'C'C'cktl  by  restlessness  and  loss  of  sleej),  the  latter  l>ein^  a  very 
common  and  Mcll-marked  symptom,  or  if  tlie  patient  do  sleep  her  rest 
is  broken  and  disturbed  by  dreams.  Causeless  dislikes  to  those  around 
her  are  often  observed  ;  the  nurse,  the  husbaniT,' tlie  dcx'tor,  or  the  ehild 
becomes  the  object  of  suspicion,  and  unless  })roj)er  care  be  taken  the  child 
may  be  seriously  injiu'ed.  As  the  disease  advances  the  ])atient  Ix'coraes 
incoherent  and  rambling  in  her  talk,  and  in  a  fully-developed  case  she 
is  incessantly  pouring  forth  an  unconnectetl  jumble  of  sentences  out  yf 
Mhich  DO  meaning;  can  be  made.  Often  some  prevalent  idea  which  is 
dwelling  in  the  patient's  mind  can  be  traced  running  through  her  rav- 
ings, and  it  has  been  noticed  that  this  is  frequently  of  a  sexual  charac- 
ter, causing  women  of  unblemished  reputation  to  use  obscene  and  dis- 
gusting language  which  it  is  difficult  to  understand  even  when  heard. 
The  tendency  of  such  patients  to  make  accasations  impugning  their 
own  chastity  was  specially  insisted  on  by  many  eminent  authorities  in 
a  recent  celebrated  trial,  when  Sir  James  Simpson  stated  that  in  Ins 
experience  "  the  organ  diseased  gave  a  type  to  the  insanity,  so  that 
with  women  suffering  from  affections  of  the  genital  organs  the  delu- 
sions would  be  more  likely  to  be  connected  with  sexual  matters." 
Religious  delusions — as  a  fear  of  eternal  damnation  or  of  having 
committed  some  unpardonable  sin — are  of  frequent  occurrence,  but 
])crhaps  more  often  in  cases  which  are  tending  to  the  melancholic  type. 
There  is  generally  intolerable  restlessness,  and  the  patient's  whole  man- 
ner and  appearance  are  those  of  excessive  excitement.  She  may  refuse 
to  remain  in  bed,  may  tear  off  her  clothes,  or  attempt  to  injure  herself 
The  suicidal  tendency  is  often  very  marked.  In  one  c-ase  under  my 
care  the  patient  made  incessant  efforts  to  destroy  hei-self,  which  were 
only  frustrated  by  the  most  careful  watching ;  she  endeavored  to 
strangle  herself  with  the  bed-clothes,  to  swallow  any  article  she  could 
lay  hold  of,  and  even  to  gouge  out  her  own  eyes.  Food  is  generally 
persistently  refused,  and  the  utmost  coaxing  may  fail  in  inducing  the 
patient  to  take  nourishment.  The  pujse  is  rapid  and  small,  and  the 
more  violent  the  excitement  and  furious  the  delirium  the  more  excited 
is  the  circulation.  The  toug;ue  is  coated  and  fiu'red,  the  bowels  consti- 
pated and  disordered,  and  the  feces  as  well  as  the  urine  are  frequently 
passed  involuntarily.  The  urine  is  scanty  and  high-colored,  and  after 
the  disease  has  lasted  for  some  time  becomes  loaded  with  phosphates. 
The  lochia  and  the  secretion  of  milk  generally  become  arrested  at  the 
commencement  of  the  disease.  The  waste  of  tissue,  from  the  incessant 
restlessness  and  movement  of  the  patient,  is  very  great,  and  if  tiie  dis- 
ease continue  for  some  time  she  falls  into  a  condition  of  marasmus, 
Avhich  may  be  so  excessive  that  she  becomes  wasted  to  a  shadow  of  her 
former  size. 

A\^j^ii,  the  insanity  assumes  the  forpi  of  jiielaacholia  its  advent  is 
more  gradual.  It  may  commence  with  depression  of  spirits  without 
any  adequate  cause,  associated  with  insomnia,  disturbed  digestion,  head- 
ache, and  other  indications  of  bodily  derangement.  Such  symptoms, 
showing  themselves  in  women  who  have  been  nursing  for  i\  length  of 
time  or  in  whom  any  other  evident  cause  of  exhaustion  exists,  should 


PUERPERAL  INSANITY.  595 

never  pass  unnoticed.  Soon  the  signs  of  mental  depression  increase 
and  positive  delusions  show  themselves.  TTiese  may  vary  much  in 
their  amount,  hut  they  are  all  more  or  less  of  the  same  tyjie,  and  very 
often  of  a  religious  character.  The  amount  of  constitutional  disturb- 
ance varies  nuich.  In  some  cases  which  a})proach  in  character  those  of 
mania  there  is  considerable  excitement,  rapid  pulse,  furred  tongue,  and 
restlessness.  Probably  cases  of  acute  melancholia,  coming  on  during 
the  puerperal  state,  most  often  assume  this  form.  In  others,  again, 
there  is  less  of  these  general  symptoms,  the  patients  are  profoundly 
dejected,  and  sit  for  hours  without  speaking  or  moving,  but  there  is  not 
nnich  excitement ;  and  this  is  the  form  most  generally  characterizing 
the  insanity  of  lactation.  In  all  cases  there  is  a  marked  disinclination 
to  food.  There  is  also,  almost  invariably,  a  disposition  to  suicide  ;  and 
it  should  never  be  forgotten  in  melancholic  cases  that  this  may  develop 
itself  in  an  instant,  and  that  a  moment's  carelessness  on  the  part  of  the 
attendants  may  lead  to  disastrous  results. 

Treatment. — Bearing  in  mind  what  has  been  said  of  the  essential 
character  of  puerperal  insanity,  it  is  obvious  that  the  course  of  treat- 
ment must  be  mainly  directed  to  maintain  the  strength  of  the  patient, 
so  as  to  enable  her  to  pass  through  the  disease  without  fatal  exhaustion 
of  the  vital  powers,  while  we  endeavor  at  the  same  time  to  calm  the 
excitement  and  give  rest  to  the  disturbed  brain.  Any  over-active 
measures — for  example,  bleeding,  blistering  the  shaven  scalp,  and  the 
like — are  distinctly  contraindicated. 

There  is  a  general  agreement  on  the  part  of  alienist  physicians  that 
in  cases  of  acute  mania  the  two  things  most  needed  are  a  sufficient 
quantity  of  suitable  food  and  sleep. 

Every  endeavor  should  be  made  to  induce  the  patient  to  take  plenty 
of  nourishment  to  remedy  the  defects  of  the  excessive  waste  of  tissue 
and  support  her  strength  until  the  disease  abates.  Dr.  Blandford,  who 
has  especially  insisted  on  the  importance  of  this,  says:^  "Now,  with\, 
regard  to  the  food,  skilful  attendants  will  coax  a  patient  into  taking  a 
large  quantity,  and  we  can  hardly  give  too  much.  Messes  of  minced 
meat  with  potato  and  greens,  diluted  with  beef-tea,  bread  and  milk,  rum 
and  milk,  arrowroot,  and  so  on,  may  be  got  down.  ('Never  give  mere 
liquids  as  long  as  you  can  get  down  solids.  \  As  the  malady  progresses 
the  tongue  and  mouth  may  become  so  dry  and  foul  that  nothing  but 
liquids  can  be  swallowed ;  but,  reserving  our  beef-tea  and  brandy,  let 
us  give  plenty  of  solid  food  while  we  can." 

The  patient  may  in  mania,  as  well  as  in  melancholia,  perhaps  even 
more  in  the  latter,  obstinately  refuse  to  take  nourishment  at  all,  and  we 
may  be  compelled  to  use  force.  Various  contrivances  have  been 
employed  for  this  purpose.  One  of  the  simplest  is  introducing  a  des- 
sert-spoon forcibly  between  the  teeth,  the  patient  being  controlled  by  an 
adequate  number  of  attendants,  and  slowly  injecting  into  the  mouth 
suitable  nourishment  by  an  india-rubber  bottle  Avith  an  ivory  nozzle, 
such  as  is  sold  by  all  chemists.  Care  must  be  taken  not  to  inject  more 
than  an  ounce  at  a  time,  and  to  allow  the  patient  to  breathe  between 
each  deglutition.     So  extreme  a  measure  will  seldom  be  required  if  the 

^  Blandford,  Insanity  and  its  Treatment. 


596  THE  rVErxPERAL  STATE. 

patient  have  experienced  attendants,  who  can  overcome  her  resistance 
to  food  by  gentler  means ;  but  it  may  be  essential,  and  it  is  far  better 
to  employ  it  than  to  allow  the  ])atient  to  become  exhausted  from  want 
of  nourishment.  In  one  case  I  had  to  feed  a  j)atient  in  this  way  three 
times  a  day  tor  several  weeks,  and  used  for  the  purpose  a  contrivance 
known  in  asylums  as  Paley's  feeding-bottle,  which  reduced  the  difficulty 
of  the  process  to  a  minimum.  Beef;tea  or  strong  soup  mixed  with 
some  farinaceous  material,  such  as  Kevalenta  Arabica  or  wheaten  flour, 
or  milk,  forms  the  best  mess  for  this  purpose. 

In  the  early  stages  the  patient  is  probably  better  without  stimulants, 
which  seem  only  to  increase  the  excitement.  As  the  disease  progi'esses 
and  exhaustion  becomes  marked,  it  may  be  necessary  to  have  recourse 
to  them.  In  melancholia  they  seem  to  be  more  useful,  and  may  be 
administered  with  greater  freedom. 

The  state  of  the  bowels  requires  special  attention.  They  are  almost 
always  disordered,  the  evacuations  being  dark  and  offensive  in  odor.  In 
the  early  stages  of  the  disease  the  prompt  clearing  of  the  bowels  by  a 
suitable  purgative  sometimes  has  the  effect  of  cutting  short  an  impend- 
ing attack.  A  curious  example  of  this  is  recorded  by  Gooch,  in  which 
the  patient's  recovery  seemed  to  date  from  the  free  evacuation  of  the 
bow'els.  A  few  grains  of  calomel  or  a  dose  of  compound  jalap  powder 
or  of  castor  oil  may  generally  be  readily  given.  During  the  continu- 
ance of  the  illness  the  state  of  the  primae  vise  should  be  attended  to, 
and  occasional  aperients  will  be  useful,  but  strong  and  repeated  purga- 
tion is  hurtful  from  the  debility  it  produces. 

One  of  the  most  important  points  of  treatment  is  to  procure^^lec}). 
For  this  purpose  there  is  no  drug  so  valuable  as  the  hydrate  of  chloral, 
either  alone  or  in  combination  with  bromide  of  sodiuiii,  which  has  a  dis- 
tinct  effect  in  increasing  its  hypnotic  action.  Given  in  a  full  dose  at 
bedtime,  say  15  gi'S.  to  3ss,  it  rarely  fails  in  procuring  at  least  some 
sleep,  and  in  the  early  stage  of  acute  mania  this  may  be  followed  by 
the  best  effects.  It  may  be  necessary  to  repeat  this  draught  night  after 
night  during  the  acute  stage  of  the  malady.  If  we  cannot  induce  the 
patient  to  swallow'  the  medicine,  it  may  be  given  in  the  form  of  enema. 

It  is  generally  admitted  that  in  mania  i)reparations  of  opium, 
formerly  much  relied  on  in  the  treatment  of  the  disease,  are  apt  to  do 
more  harm  than  good.  Dr.  Blandford  gives  a  strong  opinion  on  this 
point.  He  says:  "In  prolonged  delirious  mania  I  believe  opium 
never  does  good,  and  may  do  great  harm.  AVe  shall  see  the  effects  of 
narcotic  poisoning  if  it  be  pushed,  but  none  that  are  beneficial.  This 
applies  equally  to  opium  given  by  the  mouth  and  l)y  subcutaneous 
injection.  The  latter,  as  it  is  more  certain  and  effectual  in  producing 
good  results,  is  also  more  deadly  when  it  acts  as  a  narcotic  poison. 
After  the  administration  of  a  dose  of  morj^hia  by  the  subcutaneous 
method  the  patient  will  probably  at  once  fall  asleep,  and  we  congratu- 
late ourselves  that  our  long-wished-for  object  is  attained.  But  after  half 
an  hour  or  so  the  sleep  suddenly  terminates,  and  the  mania  and  excite- 
ment are  worse  than  before.  Here  you  may  possibly  think  that  had 
the  dose  been  larger  instead  of  half  an  hour's  sleep  you  would  have 
obtained  one  of  longer  duration,  and  you  may  administer  more,  but 


PUERPERAL  INSANITY.  597 

with  a  like  result.  Large  doses  of  nior[)]ii:i  not  merely  fail  to  produce 
refreshinj^  sleep  ;  they  poison  the  patient,  and  produce,  if  not  the  symp- 
toms of  actual  narcotic  poisoning,  at  any  rate  that  typhoid  condition 
which  indicates  prostration  and  approaching  collapse.  I  believe  there 
is  no  drug  the  use  of  which  more  often  becomes  abused  than  that  of 
opium."  It  is  otherwise  in  cases  of  melancholia,  especially  in  the  more 
chronic  forms.  In  these  oi)iates  in  moderate  doses,  not  pushed  to  excess, 
may  be  given  with  great  advantage.  The  subcutaneous  injection  of 
morphia  is  by  far  the  best  means  of  exhibiting  the  drug,  from  its  rapid- 
ity of  action  and  facility  of  administration. 

There  are  other  methods  of  calming  tiie  excitement  of  the  patient 
besides  the  use  of  luedicines.  The  prolonged  use  of  the  ^varm  bath, 
the  patient  being  immersed  in  water  at  a  temperature  of  tJTT°or9^ 
for  at  least  half  an  hour,  is  highly  recommended  by  some  as  a  sedative. 
The  wet  ])ack  serves  the  same  purpose,  and  is  more  readily  applied  in 
refractory  subjects. 

Judicious  nursing  is  of  primary  importance.  The  patient  should 
be  kept  in  a  cool,  well-ventilated,  and  somewhat  darkened  room.  If 
possible  she  shoiild  remain  in  bed^  or  at  least  endeavors  should  be  made 
to  restrain  the  excessive  restless  motion,  which  has  so  much  effect  in 
promoting  exhaustion.  ;The  presence  of  relatives  and  friends,  especially 
the  husband,  has  geuer^ly  a  prejudicial  and  exciting  effect-^  and  it  is 
advisable  to  place  the  patient  under  the  care  of  nurses  experienced  in 
the  management  of  the  insane,  who  as  strangers  are  likely  to  have  more 
control  0%'er  her.  It  is  not  too  much  to  say  that  much  of  the  success 
in  treatment  must  depend  on  the  manner  in  which  this  indication  is 
met.  Rough,  unskilled  nurses,  who  do  not  know  how  to  use  gentleness 
combined  with  firmness,  will  certainly  aggravate  and  prolong  the  dis- 
order. Inasmuch  as  no  patient  should  be  left  unwatched  by  day  or 
night,  more  than  one  nurse  is  essential. 

The  question  of  the  removal  of  the  patient  to  an  asylum  is  one  which 
will  give  rise  to  anxious  consideration.  As  the  fact  of  having  been 
under  such  restraint  of  necessity  fixes  a  certain  lasting  stigma  upon  a 
patient,  this  is  a  step  which  every  one  would  wish  to  avoid  if  possible. 
In  cases  of  acute  mania,  ^vhich  will  probably  last  a  comparatively  short 
time,  home  treatment  can  generally  be  efficiently  carried  out.  Much 
must  depend  on  the  circumstances  of  the  patient.  If  these  be  of  a 
nature  which  preclude  the  possibility  of  her  obtaining  thoroughly  effi- 
cient nursing  and  treatment  in  her  own  home,  it  is  advisable  to  remove 
her  to  a  place  where  these  essentials  can  be  obtained,  even  at  the  cost  of 
some  subsequent  annoyance.  In  cases  of  chronic  melancholia,  the  man- 
agement of  which  is  on  the  whole  more  difficult,  the  necessity  for  such 
a  measure  is  more  likely  to  arise,  and  should  not  be  postponed  too  late. 
Many  examples  of  incurable  dementia  arising  out  of  puerperal  melan- 
cholia can  be  traced  to  unnecessary  delay  in  placing  the  patients  under 
the  most  favorable  conditions  for  recovery. 

Treatment  during-  Convalescence. — When  convalescence  is  com- 
mencing change  of  air  and  scene  will  often  be  found  of  great  value. 
Removal  to^ome  quiet  country  place,  where  the  patient  can  enjoy  abun- 
dance of  air  and  exercise  in  the  company  of  her  nurses,  without  the 


598  Tin-:  rVKiiPKRAL  state. 

excitement  of  .•seeing  many  people,  is  espeeially  to  ho  reeoni mended. 
I  Great  caution  must  be  used  in  admitting  the  visits  of"  relatives  and 
friends.  In  two  ciises  under  my  own  care  the  patients  relaj)sed  when 
apparently  progressing  favorably  because  the  husl)anils  iusisteil,  contrary 
to  advice,  on  seeing  them./  On  the  other  hand,  Gooch  has  pointed  out 
that  when  the  patient  is  not  recovering,  when  month  after  month  has 
been  passed  in  seclusion  without  any  improvement,  the  visit  of  a  friend 
or  relative  may  produce  a  favorable  moral  impression  and  inaugurate  a 
change  for  the  i)etter.  \  It  is  i)robably  in  cases  of  melancholia,  rather 
than  in  mania,  that  this  is  likely  to  hap])en.  The  exi)eriment  may 
under  such  circumstances  be  worth  trying,  but  it  is  one  the  result  of 
which  we  must  contemplate  with  some  anxiety. 


CHAPTER   A\ 
PUERPERAL    SEPTICEMIA. 

Difference  of  Opinion  as  to  Puerperal  Fever. — There  is  no 
subject  in  the  whole  range  of  obstetrics  which  has  cau.sed  so  much 
discassion  and  difference  of  opinion  as  that  to  which  this  chapter 
is  devoted.  Under  the  name  of  "  puerperal  fever "  the  di-sejise  we 
have  to  consider  has  given  rise  to  endless  controversy.  One  writer 
after  another  has  stated  his  view  of  the  nature  of  the  affection  with 
dogmatic  precision,  often  on  no  other  grounds  than  his  own  preconceived 
notions  and  an  erroneous  inter})retation  of  some  of  the  })ost-mortem 
appearances.  Thus,  one  states  that  puerperal  fever  is  only  a  local 
inflammation,  such  as  peritonitis;  others  declare  it  to  be  phlebitis,  metri- 
tis, metro-peritonitis,  or  an  essential  zymotic  disease,  sui  generis,  which 
affects  lying-in  women  only.  The  result  has  been  a  hopeless  confusion, 
and  the  student  rises  from  the  study  of  the  sul)ject  with  little  more  n.sc- 
ful  knowledge  than  when  he  began.  Fortunately,  modern  research  is 
beginning  to  throw  a  little  ligiit  upon  this  chaos. 

Modern  View  of  the  Disease. — The  whole  tendency  of  recent 
investigation  is  daily  rendering  it  more  and  more  certain  that  obstetri- 
cians have  been  led  into  error  by  the  special  virulence  and  inteusitA'  of 
the  di.sease,  and  that  they  have  erroneously  considered  it  to  lie  some- 
thing special  to  the  puerperal  state,  in.stead  of  recognizing  in  it  a  form 
of  septic  disea.se  practically  identical  with  that  which  is  familiar  to  .sur- 
geons under  the  name  of  pytemia  or  septicaemia. 

If  this  view  be  correct,  the  term  "  jnierperal  fever,"  conveying  the 
idea  of  a  fever  such  as  typhus  or  tyjihoid,  nuist  be  acknowledged  to  be 
mi.sleading,  and  one  that  should  be  discarded  as  only  tending  to  confu- 
sion.    Before  di.scu.ssing  at  length  the  reasons  which  render  it  probable 


PUERPERAL  SEPTICEMIA.  599 

that  the  disease  is  in  no  way  spceifie  or  j)efuliar  to  the  puerperal  state, 
it  will  be  well  to  relate  briefly  some  of"  the  leadiiii^  facts  connected  with  it. 

History. — More  or  less  distinct  references  to  the  existence  of  the 
so-called  ])uerperal  fever  are  met  with  in  the  classical  authors,  proving 
beyond  doubt  that  the  disease  was  well  known  to  them ;  and  Hippoc- 
rates, besides  relating  several  cases  the  nature  of  which  is  unquestion- 
able, clearly  recognizes  the  possibility  of  its  originating  in  the  retention 
and  decomposition  of  jwrtions  of  the  placenta.  Although  Harvey  and 
other  writers  showed  that  they  were  more  or  less  familiar  wath  it,  and 
even  made  most  creditable  observations  on  its  etiology,  it  was  not  until 
the  latter  half  of  the  last  century  that  it  came  prominently  into  notice. 
At  that  time  the  frightful  mortality  occurring  in  some  of  the  principal 
lying-in  hospitals,  especially  in  the  Hotel  Dieu  at  Paris,  attracted  atten- 
tion, and  ever  since  the  disease  has  been  familiar  to  obstetricians. 

Mortality  in  Lying-in  Hospitals. — Its  prevalence  in  hospitals  in 
which  lying-in  women  are  congregated  has  been  constantly  observed  both 
in  England  and  elsewhere,  occasionally  producing  an  appalling  death- 
rate,  the  disease,  when  once  it  has  appeared,  frequently  spreading  from 
one  patient  to  another  in  spite  of  all  that  could  be  done  to  arrest  it.  It 
would  be  easy  to  give  many  startling  instances  of  this.  Thus  it  pre- 
vailed in  London  in  the  years  1760,  1768,  and  1770  to  such  an  extent 
that  in  some  lying-in  institutions  nearly  all  the  patients  died.  Of  the 
Edinburgh  Infirmary  in  1773  it  is  stated  that  "almost  every  woman  as 
soon  as  she  was  delivered,  or  perhaps  about  twenty-four  hours  after,  was 
seized  with  it,  and  all  of  them  died,  though  every  method  was  used  to 
cure  the  disorder."  On  the  Continent,  where  the  lying-in  institutions 
are  on  a  much  larger  scale,  the  mortality  was  equally  great.  Thus  in 
the  Maisou  d'Accouchements  of  Paris  in  a  number  of  different  years 
sometimes  as  many  as  1  in  3  of  the  women  delivered  died,  on  one 
occasion  10  women  dying  out  of  15  delivered.  Similar  results  were 
observed  in  other  great  continental  hospitals,  as  in  Vienna,  where,  in 
1823,  19  per  cent,  of  the  cases  died,  and  in  1842,  16  per  cent.;  and  in 
Berlin  in  1862  hardly  a  single  patient  escaped,  the  hospital  being 
eventually  closed. 

Such  facts,  the  correctness  of  which  is  beyond  any  question,  prove  to 
demonstration  the  great  risk  which  may  accompany  the  aggregation  of 
lying-in  women.  Whether  they  justify  the  conclusion  that  all  lying- 
in  hospitals  should  be  abolished  is  another  and  a  very  wide  question 
which  can  scarcely  be  satisfactorily  discussed  in  a  practical  work.  It  is 
to  be  observed,  however,  that  most  of  the  cases  in  which  the  disease 
produced  such  disastrous  results  occurred  before  our  more  recent  know- 
ledge of  its  mode  of  propagation  was  acquired,  M'lien  no  sufficient  hygienic 
precautions  were  adopted,  when  ventilation  was  little  thought  of,  and 
when,  in  a  Avord,  every  condition  prevailed  that  would  tend  to  favor  the 
spread  of  a  contagious  disease  from  one  patient  to  another.  ]\Iore  recent 
experience  proves  that  when  the  contrary  is  the  case  the  occurrence  of 
epidemics  of  this  kind  may  be  entirely  prevented  and  the  mortality 
approximated  to  that  of  home  practice.  The  results  almost  universally 
obtained  of  late  years  by  the  introduction  of  strict  antisepsis  into  lying- 
in  institutions  aflbrd  a  most  instructive  commentary  on  the  causes  of 


GOO  THE  PUERPERAL  STATE. 

puerperal  fever.  Thus,  in  the  Maternite  in  Paris  tlie  mortality  from 
1858  to  1870  was  1  in  11  ;  at  the  present  time  it  is  only  1  in  100.  At 
the  Foundlinti-  Hospital  in  St.  Petersburg-  the  mortality  before  the  intro- 
duction of  antiseptics  was  1  in  27  ;  since  their  use,  1  in  147,  Similar 
satisfactory  results  have  been  reported  in  lying-in  institutions  in  London, 
America,  and  indeed  universally  whatever  antiseptic  precautions  have 
been  adopted.^ 

The  more  closely  the  history  of  these  outbreaks  in  hospitals  is  studied, 
the  more  apjnuvnt  does  it  become  that  they  are  not  dependent  on  miasm 
necessarily  j)roduced  by  the  aggregation  of  puer]>eral  patients,  but  on 
the  direct  conveyance  of  septic  matter  from  one  patient  to  another. 

In  numerous  instances  the  disease  has  been  said  to  be  generally 
epidemic  in  domiciliary  jDractice,  much  in  the  same  way  as  scarlet 
fever  or  any  zymotic  complaint  might  be.  Such  e])idemics  are  described 
as  having  occurred  in  Loudon  in  1827-28,  in  Leeds  in  1809-12,  in 
Edinburgh  in  1825,  and  many  others  might  be  cited.  (There  is,  liow- 
ever,  no  sufficient  ground  for  believing  that  the  disease  has  ever  been 
epidemic  in  the  strict  sense  of  the  w^ord.\  That  numerous  cases  have 
often  occurred  in  the  same  place  and  at  the  same  time  is  beyond  ques- 
tion, but  this  can  easily  be  explained  without  admitting  an  epidemic 
influence,  knowing,  as  we  do,  how  readily  septic  matter  may  be  con- 
veyed from  one  patient  to  another.  In  many  of  the  so-called  epidemics 
the  disease  has  been  limited  to  the  patients  of  certain  midwives  or  prac- 
titioners, while  those  of  others  have  entirely  escaped — a  fact  easily  under- 
stood on  the  assumption  of  the  disease  being  produced  by  septic  matter 
conveyed  to  the  patient,  but  irreconcilable  with  the  view  of  general 
epidemic  influence.  We  are  not  in  possession  of  any  reliable  statistics 
of  the  mortality  arising  from  puerperal  septicaemia  in  ordinary  general 
practice.  It  has,  however,  been  m'cII  pointed  out  in  the  re})ort  on  puer- 
peral fever  presented  by  the  Obstetrical  Society  of  Berlin  to  the  Prussian 
minister  of  health  ^  that  not  only  do  the  published  returns  of  death  from 
metria  afford  no  reliable  estimate  of  the  actual  mortality  from  this  source, 
but  that  they  arc  very  far  more  numerous  than  deaths  from  any  other 
cause  in  connection  with  pregnancy  and  childbirth. 

Theories  Advanced  Regarding  its  Nature. — It  would  be  a  useless 
task  to  detail  at  length  the  theories  that  have  been  advanced  to  explain 
the  (.lisease.  Indeed,  it  may  safely  be  held  that  the  supposed  necessity 
of  providing  a  theory  which  would  explain  all  the  facts  of  the  disease 
lias  done  more  to  surround  it  with  obscurity  than  even  the  difticulties 
of  the  sul)ject  itself.  If  any  real  advance  is  to  be  made,  it  can  only  be 
Ijy  adopting  a  humble  attitude,  by  admitting  that  we  are  only  on  the 
threshold  of  the  inquiry,  and  by  a  careful  observation  of  clinical  facts 
without  drawing  from  them  too  positive  deductions. 

Theory  of  its  Local  Origin. — ]\Iany  have  taught  that  the  disease 
is  essentially  a  local  inflannnation,  pnuhicing  secondary  constitutional 
effects.     This  view  doubtless  originated  from  too  exclusive  attention 

'See  "The  Prevention  of  Lving-in  Fever,"  bv  Wassily  Sutugin,  Edin.  Med.  Joimi., 
vol.  1884-85,  p.  781. 

^ "  Dentschrift  der  Puerperalfieber-Commission,"  Zcitschrift  f.  Geh.  u.  Gyn.,  1878, 
Band  iii.  S.  1,  translated  in  Ediu.  Med.  Journ.,  vol.  1878-79,  p.  435. 


PUERPERAL  SEPTICAEMIA.  601 

to  the  inorbitl  cliangcs  luuiul  on  post-mortem  examination.  Extensi\'(! 
peritonitis,  phlebitis,  inflammation  of  the  lymphatics  or  of  the  tissues 
of  the  uterus  arc  very  commonly  found  after  death  ;  and  eacii  of  these 
lias  in  its  turn  been  believed  to  be  the  real  source  of  the  disease.  This 
view  finds  but  little  favor  with  modern  pathologists,  and  is  in  so 
many  ways  inconsistent  with  clinical  facts  that  it  may  be  considered  to 
be  obsolete.  No  one  of  the  conditions  above  mentioned  is  universally 
found,  and  in  the  worst  cases  definite  signs  of  local  inflammation  may 
be  entirely  absent.  Nor  will  this  theory  explain  the  conveyance  of  the 
disease  from  one  patient  to  another  or  the  peculiar  severity  of  the  con- 
stitutional symptoms. 

Theory  of  an  Essential  Zymotic  Fever. — A  more  admissible 
theory,  and  one  which  has  been  extensively  entertained,  is  that  there 
is  an  essential  zymotic  fever  peculiar  to,  and  only  attacking,  puerperal 
women,  which  is  as  specific  in  its  nature  as  typhus  or  typhoid,  and  to 
which  the  local  phenomena  observed  after  death  bear  the  same  relation 
t>hat  the  pustules  on  the  skin  do  to  smallpox  or  the  ulcers  in  the  intes- 
tinal glands  to  typhoid.  This  fever  is  supposed  to  spread  by  contagion 
and  infection,  and  to  prevail  epidemically  both  in  private  and  in  hos- 
pital practice.  The  most  recent  exponent  of  this  view  is  Fordyce 
Barker,  who  in  his  excellent  work  on  the  Puerperal  Diseases  has 
entered  at  length  into  all  the  theories  of  the  disease.  He,  like  others 
who  hold  his  opinions,  has,  I  cannot  but  think,  entirely  failed  to  bring 
forward  any  conclusive  evidence  of  the  existence  of  such  a  specific  fever. 
It  is  no  doubt  true  that  in  typhus  and  typhoid  and  other  undoubted 
examples  of  this  class  of  disease  there  are  well-marked  local  secondary 
phenomena,  but  then  they  are  distinct  and  constant.  He  makes  no 
attempt  to  prove  that  anything  of  the  kind  occurs  in  puerperal  fever. 
On  the  contrary,  probably  there  are  no  two  cases  in  M'hich  similar  local 
phenomena  occur,  nor  is  there  any  case  in  which  the  most  practised 
obstetrician  could  foretell  either  the  course  and  the  duration  of  the  ill- 
ness or  the  local  phenomena.  Again,  this  theory  altogether  fails  to 
explain  the  very  important  class  of  cases  which  can  be  distinctly  traced 
to  sources  originating  in  the  patient  herself — viz.  the  absorption  of  septic 
matter  from  decomposing  coagula  and  the  like.  Barker  meets  this  dif- 
ficulty by  placing  such  cases  of  auto-infection  under  a  separate  category, 
admitting  that  they  are  examples  of  septicaemia.  But  he  fails  to  show 
that  there  is  any  difference  in  symptomatology  or  post-mortem  signs 
between  them  and  the  cases  he  believes  to  depend  on  an  essential  fever; 
nor  would  it  be  possible  to  distinguish  the  one  from  the  other  by  either 
their  clinical  or  pathological   history. 

Theory  of  its  Identity  "with  Surgical  Septiceemia. — The  modern 
view,  which  holds  that  the  disease  is,  in  fact,  identical  with  the  condi- 
tion known  a.s  pyaemia  or  septicaemia,  is  by  no  means  free  from  objec- 
tions, and  nuich  patient  clinical  investigation  is  required  to  give  a  satis- 
factory explanation  of  certain  peculiarities  Avhich  the  disease  presents; 
but  in  sjjite  of  these  difficulties,  which  time  may  serve  to  remove,  it 
offers  a  far  better  explanation  of  the  phenomena  observed  than  any 
other  that  has  yet  been  advanced. 

According  to  this  theory,  the  so-called  puerperal  fever  is  produced  by 


602  THE  PUERPERAL  STATE. 

the  absorption  of  septic  matter  into  the  system  through  solutions  of 
continuity  in  the  generative  tract,  such  as  always  exist  after  labor.  It 
is  not  essential  that  the  poison  should  be  })eculiar  or  speeitic;  for,  just 
as  in  surgical  pyremia,  any  decomposing  organic  matter,  either  originat- 
ing within  the  generative  organs  of  the  patient  herself  or  coming  from 
without,  may  set  uj)  the  morbid  action. 

In  deseril)ing  the  disease  under  discussion  1  shall  assume  that,  so  far 
as  our  present  knowledge  goes,  this  view  is  the  one  most  consonant  with 
facts ;  but,  bearing  in  mind  that  very  little  is  yet  known  of  surgical 
septicaemia,  it  must  not  be  expected  that  obstetricians  can  satisfactorily 
explain  all  the  phenomena  they  observe. 

The  best  basis  of  description  I  know  of  is  that  given  by  Burdon 
Sanderson,  when  he  says  :  "  In  every  pysemic  process  you  may  trace  a 
focus,  a  centre  of  origin,  lines  of  diffusion  or  distribution,  and  secondary 
results  from  the  distribution — in  every  case  an  initial  process  from  which 
infection  commences,  from  which  the  infection  spreads,  and  secondary 
processes  which  come  out  of  this  primary  one."  ^  Adopting  this  divis- 
ion, I  shall  first  treat  of  the  mode  in  which  the  infection  may  com- 
mence in  obstetric  cases,  and  point  out  the  special  difficulties  which 
this  part  of  the  subject  presents. 

Channels  through  -which  Septic  Matter  may  be  Absorbed. — 
The  fact  that  all  recently-delivered  women  present  lesions  of  continuity 
in  the  generative  tract,  through  which  septic  matter,  brought  into  con- 
tact with  them,  may  be  readily  absorbed,  has  long  been  recognized. 
The  analogy  between  the  interior  of  the  uterus  after  delivery  and  the 
surface  of  a  stump  after  amputation  w^as  particularly  insisted  on  by 
Cruveilhier,  Simpson,  and  others — an  analogy  which  was,  to  a  great 
extent,  based  on  erroneous  conceptions  of  what  took  place,  since  they 
conceived  that  the  whole  interior  of  the  uterus  w-as  bared.  It  is  now 
well  known- that  this  is  not  the  case;  but  the  fact  remains  that^at  the 
placental  site,  at  any  rate,  there  are  open  vessels  through  which  absor])- 
tion  may  readily  take  place.j  That  absorption  of  septic  material  occurs 
through  this  channel  is  prdftable  in  certain  cases  in  W'hich  decomposing 
materials  exist  in  the  interior  of  the  uterus,  especially  when  from 
defective  uterine  contraction  the  venous  sinuses  are  abnormally  patu- 
lous and  are  not  occluded  by  thrombi.  It  is  difficult  to  understand 
how  septic  matter,  introduced  from  without,  can  reach  the  placental 
site.  Other  sites  of  absorption  are,  however,  ahvays  available.  These 
exist  in  every  case  in  the  form  of  slight  abrasions  or  lacerations  about 
the  cervix  or  in  the  vagina,  or,  especially  in  primiparje,  about  the  four- 
chette  and  perineum.  There  is  even  some  reason  to  think  that  absorp- 
tion of  septic  matter  may  take  place  through  the  mucous  membrane  of 
the.  vagina  or  cervix  without  any  breach  of  surface.  This  might  serve 
to  account  for  the  occasional,  although  rare,  cases  in  which  symptoms 
of  the  disease  develop  themselves  before  delivery,  or  so  soon  after  it  as 
to  show  that  the  infection  must  have  jireceded  labor ;( nor  is  there  any 
inherent  improbability  in  the  su[)position  that  septic  material  may  be  A 
occasionally  absorbed  through  the  unbroken  mucous  membrane,  as  is  \ 
certainly  the  case  with  some  poisons — for  example,  that  of  syphilis. [/| 
'  Clinical  Transactions,  vol.  vii.  p.  cviii. 


PUERPEBAL  SEPTICEMIA.  603 

Hence  there  is  no  difficulty  in  recognizing  the  similarity  of  a  lying-in 
woman  to  a  patient  sutilering  from  a  recent  .surgical  lesion,  or  in  under- 
standing how  se})tic  matter  conveyed  to  her  during  or  shortly  after  labor 
may  be  absorbed.  It  is  necessary,  however,  to  suppose  that  absorption 
takes  place  immediately  or  very  shortly  after  these  lesions  of  continuity 
are  formed,  for  it  is  well  known  that  the  ])Ower  of  absorption  is  arrested 
after  they  have  commenced  to  heal.  This  fact  may  explain  the  cases 
in  which  sloughing  about  the  perineum  or  vagina  exists  without  any 
septicaemia  resulting,  or  the  far  from  uncommon  cases  iu  which  an 
intensely  fetid  lochial  discharge  may  be  present  a  few  days  after 
delivery  without  any  infection  taking  place. 

The  character  and  sources  of  the  septic  matter  constitute  one  of  the 
most  obscure  questions  iu  connection  with  septicaemia,  and  that  which 
is  most  open  to  discussion. 

Division  into  ATitogenetic  and  Heterog-enetic  Cases. — The  most 
practical  division  of  the  subject  is  into  cases  in  which  the  septic  matter 
originates  within  the  patient,  so  that  she  infects  herself,  the  disease  then 
being  properly  autogenetic ;  and  into  those  in  which  the  septic  matter 
is  conveyed  from* without  and  brought  into  contact  with  absorptive 
surfaces    iu  the  generative  tract,  the  disease  then  being  Jieterogenetic. 

Sources  of  Self-infection. — The  sources  of  auto-infection  may  be 
various,  but  they  are  not  difficult  to  understand,  ^ny  condition  giving 
ri^!i£_i2.,tl^£Qmpositiou,  either  of  the  tissues  of  the  mother  herself,  of 
matters  retained  in  the  uterus  or  vagina  that  ought  to  have  been  expelled, 
or  decomposing  matter  derived  from  a  putrid  foetus,  may  start  the  sep- 
ticsemic  process.  J  Thus  it  may  happen  that  from  continuous  pressure  on 
the  maternal  soft  parts  dui'ing  labor  sloughing  has  set  in,  or  there  may 
be  already  decomposing  material  present  from  some  previous  morbid 
state  of  the  genital  tracts,  as  in  carcinoma.  A  more  common  origin  is 
the  retention  of  coagula  or  of  small  portions  of  membrane  or  of  pla- 
centa in  tKeTntertoFof  the  uterus,  w^hich  have  putrefied  from  access  of 
air;  or  in  the  decomposition  of  the  lochia.  That  the  retention  of  por- 
tions of  the  placental  tissue  has  at  all  times  been  the  cause  of  septicae- 
mia may  be  illustrated  by  the  case  of  the  Duchesse  d'Orleans  (iu  the 
time  of  Louis  XIII.),  who  had  an  easy  labor,  but  died  of  childbed 
fever.  An  examination  was  made  by  the  leading  physicians  of  Paris, 
in  their  report  of  which  it  was  stated:  "On  the  right  side  of  the  womb 
was  found  a  small  jjortion  of  after-birth,  so  firmly  adherent  that  it 
could  hardly  be  torn  off  by  the  finger-nails."^  The  reason  why  self- 
infection  does  not  more  often  occur  from  such  sources,  since  more  or 
less  decomposition  is  of  necessity  so  often  present,  has  already  been 
referred  to  in  the  fact  that  absorption  of  such  matters  is  not  apt  to  occur 
when  the  lesions  of  continuity,  always  existing  after  parturition,  have 
commenced  to  heal.  This  observation  may  also  serve  to  explain  how 
previous  l^ad  states  of  health,  by  interfering  with  the  healthy  reparative 
process  occurring  after  delivery,  may  predispose  to  self-infection.  It  is 
interesting  to  note  that  puerperal  septicaemia  arising  from  such  sources 
is  not  limited  to  the  human  race.  In  the  debate  on  pya?mia  at  the 
Clinical  Society,  Mr.  Hutchinson  recorded  several  well-marked  exam- 

^  Louise  Pourgeok,  by  Goodell. 


604  THf:  PUERPERAL  STATE. 

pies  oecuring  in  o\ve>  in  ^^■ll<)^(■  nteii  portions  of  retained  placenta  were 
Ibuntl. 

Source  of  Heterog-enetic  Infection. — Tlie  sources  of  septic  matter 
conveyed  Irojn  witlmnt  aiv  luucli  more  difficult  to  trace,  and  there  are 
many  facts  connected  with  hetero<^enetic  inl'ection  which  are  very  diffi- 
cult to  reconcile  with  theory,  and  of  which,  it  nuist  be  admitted,  we 
are  not  yet  able  to  give  a  satisfactory  explanation. 

It  is  probable  that  any  decomposing  organic  matter  may  infect,  l)Ut 
that  some  forms  operate  with  more  certainty  and  greater  virulence  than 
others. 

One  of  these,  which  has  attracted  special  attention,  is  what  may  be 
termed  cadaveric  poison,  derived  from  dissection  of  the  dead  subject  in 
the  anatoluicaT  aiicl  post-mortem  theatres,  and  conveyed  to  the  genital 
tract  by  the  hands  of  the  accoucheur.  Attention  was  pai-ticularly 
dh-ected  to  this  source  of  infection  by  the  observations  of  Semmelweiss, 
who  showed  that  in  the  division  of  the  Vienna  Lying-in  Hospital 
attended  by  medical  men  and  students  wlio  frequented  the  dissecting- 
rooms  the  mortality  was  seldom  less  than  1  to  10,  while  in  the  division 
solely  attended  Iw  women  the  mortality  never  exceeded  1  to  34 ;  the 
number  of  deaths  in  the  former  division  at  once  falling  to  that  of  the 
latter  so  soon  as  proper  precautions  and  means  of  disinfection  were  used. 
Manv  other  facts  of  a  like  nature  have  since  been  recorded  which  ren- 
der this  origin  of  puerperal  septicaemia  a  matter  of  certainty.  An 
interesting  example  is  related  by  Simjison  with  characteristic  candor : 
"In  1836  or  1837,  !Mr.  Sidey  of  this  city  had  a  rapid  succession  of  five 
or  six  cases  of  puerperal  fever  in  his  practice  at  a  time  when  the  dis- 
ease was  not  known  to  exist  in  the  practice  of  any  other  practitioners  in 
the  localitv.  Dr.  Simpson,  who  had  then  no  firm  or  proper  belief  in 
the  contagious  propagation  of  puerperal  fever,  attended  the  dissection  of 
Mr.  Sidev's  patients  and  freely  handled  the  diseased  i)arts.  The  next 
four  cases  of  midwifery  which  Dr.  Simpson  attended  were  all  atiected 
with  puerperal  fever,  and  it  was  the  first  time  he  had  seen  it  in  jirac- 
tice.  Dr.  Patterson  of  Leith  examined  the  ovaries,  etc.  The  three 
next  cases  which  Dr.  Patterson  attended  in  that  town  were  attacked 
W'ith  the  disease."'  Negative  examples  are  of  course  brought  forward 
of  those  who  have  attended  post-mortem  examinations  without  injuiy 
to  their  obstetric  patients,  which  merely  prove  that  the  cadaveric  poison 
does  not,  of  necessity,  attach  itself  to  the  hands  of  the  di&sector;  and 
no  amount  of  such  testimony  can  invalidate  such  positive  evidence  as 
that  Just  narrated.  Barnes  Ix'lieves  that  there  is  not  so  much  danger 
attending  the  dissection  of  ])atients  who  have  died  of  any  ordinary  dis- 
ease, but  that  the  risk  attending  the  dissection  of  those  who  have  died 
of  infectious  or  contagious  complaints  is  very  great  indeed."  I  })re- 
surae  there  is  no  doubt  that  the  risk  is  greater  when  the  subject  has  died 
from  zymotic  disease ;  but  the  distinction  is  too  delicate  to  rely  on,  and 
the  attendant  on  midwifery  will  certainly  err  on  the  safe  side  by  avoid- 
ing as  much  as  possible  having  anything  to  do  Avith  the  conduct  of  dis- 
sections or  post-mortem  examinations. 

^Selected  Obstet.  Worh,  p.  508. 

*■'  Lectures  on  Puerperal  Fever,"  Lancet,  18G5,  vol.  ii.  p.  112. 


PUERPERAL  SEPTICEMIA.  605 

Infection  from  Erysipelas. — Another  })o.s.sible  source  of  infectioii  is 
erysipelatous  disease  in  all  its  forms.  The  intimate  connection  between 
erysipelas  and  surgical  pytemia  has  long  been  recognized  by  sui-geons, 
and  the  inHuence  of  erysipelas  in  producing  puei-peral  septicaemia  has 
been  specially  observed  in  surgical  hospitals  into  wliicli  lying-in  |)atients 
were  also  admitted.  Trousseau  relates  instances  of  this  kind  occurring 
in  Paris.  The  only  instance  that  I  know  of  in  London  was  in  the 
lying-in  Avard  of  King's  College  Hospital,  where,  in  spite  of  every 
hygienic  precaution,  the  mortality  was  so  great  as  to  necessitate  the 
closure  of  the  ward.  Here  the  association  of  erysij)elas  with  puci-peral 
septicaemia  was  again  and  again  observed,  the  latter  proving  fatal  in 
direct  proportion  to  the  prevalence  of  the  former  in  the  surgical  wards. 
The  dependence  of  the  two  on  the  same  poison  was  in  one  instance 
curiously  shown  by  the  fact  of  the  child  of  a  patient  who  died  of  puer- 
peral septicaemia  dying  from  erysipelas  which  started  from  a  slight  abra- 
sion produced  by  the  forceps.  A  more  recent  and  very  remarkable 
example  is  related  by  Dr.  Lombe  Atthill.'  A  patient  suffering  from 
erysipelas  was  admitted  into  the  Rotunda  Hospital  on  February  15, 
1877.  The  sanitary  condition  of  the  hospital  was  at  the  time  excel- 
lent. The  patient  was  removed  next  day,  but  of  the  next  10  patients 
confined  in  adjoining  wards,  9  were  attacked  with  puerperal  peritonitis, 
the  only  one  who  escaped  being  a  case  of  abortion.  But  the  connection 
between  erysipelas  and  puerperal  septicaemia  is  not  limited  to  hospitals, 
having  been  often  observed  in  domiciliary  practice.  Some  interesting 
facts  have  been  collected  by  Dr.  Minor,^  who  has  shown  that  the  two 
diseases  have  frequently  prevailed  together  in  various  parts  of  the 
United  States,  and  that  during  a  recent  outbreak  of  puerperal  fever  in 
Cincinnati  it  occurred  chiefly  in  the  practice  of  those  physicians  who 
attended  cases  of  erysipelas.  Many  children  also  died  from  erysipelas 
whose  mothers  had  died  from  puerperal  fever. 

Infection  from  Other  Zymotic  Diseases. — There  is  good  reason  to 
believe  that  thecontagium  of  other  zymotic  diseases  may  produce  a  form 
of  disease  indistinguishable  from  ordinary  puerperal  septicaemia,  and 
presenting  none  of  the  characteristic  features  of  the  specific  complaint 
from  which  the  contagium  was  derived.  This  is  admitted  to  be  a  fact 
by  the  majority  of  the  most  eminent  British  obstetricians,  although  it 
does  not  seem  to  be  allowed  by  continental  authorities,  and  it  is  strongly 
controverted  by  some  writers  in  Great  Britain.  It  is  certainly  difficult 
to  reconcile  this  with  the  theory  of  septicaemia,  and  we  are  not  in  a  posi- 
tion to  give  a  satisfactory  explanation  of  it.  I  believe,  however,  that 
the  evidence  in  favor  of  the  possibility  of  puerperal  septicaemia  origi- 
nating in  this  way  is  too  strong  to  be  assailable. 

The  scarlatinal  poison  is  that  regarding  which  the  greatest  nund)er 
of  observations  have  Been  made.  Numerous  cases  of  this  kind  are  to 
be  found  scattered  through  our  obstetric  literature,  but  the  largest  num- 
ber are  to  be  met  with  in  a  paper  by  Dr.  Braxton  Hicks  in  the  twelfth 
volume  of  the  Obstetrical  Transactions,  and  they  are  especially  valuable 
from  that  gentleman's  well-known  accuracy  as  a  clinical  observer.    Out 

^Medical  Press  aiul  Circular,  Januarv-.Tune,  1877,  p.  339. 
^Erysipelas  and  Childbed  Fevir,  Cincinnati,  1874. 


606  THE  PUERPERAL  STATE. 

of  Q^  cases  of  puerperal  disease  seen  in  consultation,  no  less  than  37 
.were  distinctly  traced  to  the  scarlatinal  poison.  Of  these,  20  had  the 
characteristic  rash  of  the  disease,  but  the  remaining  17,  although  the 
history  clearly  proved  exposure  to  the  contagium  of  scarlet  fever,  showed 
none  of  its  usual  symptoms,  and  were  not  to  be  distinguished  from  ordi- 
nary typical  cases  of  the  so-called  puerperal  fever.  On  the  theory  tliat 
it  is  impossible  for  the  specific  contagious  diseases  to  be  modified  by  the 
puerperal  state,  we  have  to  admit  that  one  physician  met  with  17  cases 
of  puerperal  septicsemia  in  which,  by  a  mere  coincidence,  the  contagium 
of  scarlet  fever  had  been  traced,  and  that  the  disease  nevertheless  origi- 
nated from  some  other  source — an  hyjsothesis  so  improbable  that  its 
mere  mention  carries  its  own  refutation. 

With  regard  to  the  other  zymotic  diseases  the  evidence  is  not  so 
strong,  probably  from  the  comparative  rarity  of  the  diseases.  Hicks 
mentions  one  case  in  which  the  diphtheritic  poison  was  traced,  although 
none  of  the  usual  phenomena  of  the  disease  were  present.  I  lately  saw 
a  case  in  which  a  lady  a  few  days  after  delivery  had  a  very  serious 
attack  of  septicaemia  without  any  diphtheritic  symptoms,  her  husband 
being  at  the  same  time  attacked  with  diphtheria  of  a  most  marked  type. 
Here  it  would  be  difficult  not  to  admit  the  dependence  of  the  two  dis- 
eases on  the  same  poison. 

!It  is,  however,  certain  that  all  the  zymotic  diseases  may  attack  a 
newly-delivered  woman  and  run  their  characteristic  course  without  any 
peculiar  intensity.  Probably  most  practitioners  have  seen  cases  of  this 
kind ;  and  this  is  precisely  one  of  the  points  of  difficulty  which  we 
cannot  at  present  explain,  but  on  which  future  research  may  be  expected 
to  throw  some  light.  It  seems  to  me  not  improbable  that  the  explana- 
tion of  the  fact  that  zymotic  poison  may  in  one.  puerperal  patient  run 
its  ordinary  course,  and  in  another  produce  symptoms  of  intense  septi- 
ceemia,  may  be  found  in  the  channel  of  absorption.  It  is,  at  any  rate, 
comprehensible  that  if  the  contagium  be  absorbed  through  the  skin  or 
the  ordinary  channel  it  may  produce  its  characteristic  symptoms  and 
run  its  usual  course,  while  if  brought  into  contact  with  lesions  of  con- 
tinuity in  the  generative  tract  it  may  act  more  in  the  way  of  septic  poi- 
son, or  with  such  intensity  that  its  specific  symptoms  are  not  developed. 

It  may  reasonably  be  objected  that  if  puerperal  and  surgical  septice- 
mia be  identical,  the  zymotic  poisons  ought  to  be  similarly  modified 
when  they  affect  patients  after  surgical  operations.  The  subject  of  spe- 
cific contagium  as  a  cause  of  surgical  pytemia  has  been  so  little  studied 
that  I  do  not  think  any  one  would  be  justified  in  asserting  that  such  an 
occurrence  is  not  possible.  Fritsch  of  Halle  and  other  German  physi- 
cians have  recently  shown  how  elaborate  antiseptic  precautions  in 
lying-in  hospitals  may  prevent  the  origin  of  the  disease  from  such 
sources.  Sir  James  Paget  in  his  Clinical  Lectures  seems  to  believe  in 
the  possibility  of  such  modification.  He  says  :  "  I  think  it  not  improb- 
able that  in  some  cases  results  occurring  with  obscure  symptoms  within 
two  or  three  days  after  operations  have  been  due  to  scarlet-fever  poison, 
hindered  in  some  way  from  its  usual  progress."  Sir  Spencer  Wells 
informs  me  that  he  has  seen  cases  of  surgical  pyaemia  which  he  had 
reason  to  believe  originated  in  the  scarlatinal  poison ;  and  his  well- 


PUERPERAL  SEPTICEMIA.  607 

known  success  as  an  ovariotomist  is  no  doubt  in  a  great  measure  to  be 
attributed  to  his  extreme  care  in  seeing  that  no  one  likely  to  come  in 
contact  with  his  patients  has  been  exposed  to  any  such  source  of  infec- 
tion. 

Sewer  Gas  and  Defective  Sanitary  Arrangements. — Exposure 
to  sewer ^-as  may,  I  feel  sure,  produce  the  disease.  In  two  cases  of  the 
kind  i  had  the  opportunity  of  closely  watching  an  untrapped  drain 
opened  directly  into  the  bedroom — in  one  instance  into"  a  bath,  in  the 
other  into  a  water-closet.  Both  cases  were  indistinguishable  from  the 
ordinary  form  of  the  disease,  and  in  both  improvement  commenced  as 
soon  as  the  patient  was  removed  into  another  room. 

In  a  case  I  saw  some  years  ago  in  dotting  Hill,  the  patient,  who  had 
been  confined  within  a  week,  had  all  the  symptoms  of  a  most  intense 
attack  of  septicaemia,  but  none  of  a  diphtheritic  character,  while  her 
husband  lay  in  an  adjoining  room  suffering  from  a  diphtheritic  sore 
throat.  Here  the  waste-pipe  of  the  bath  was  found  to  communicate 
directly  with  the  sewer.  In  spite  of  her  intense  illness  I  had  the 
patient  removed  to  another  house,  and  from  that  moment  she  began  to 
improve.  In  two  other  cases  in  which  the  same  source  of  disease  was 
detected  the  removal  of  the  patient  from  the  infected  atmosphere  was 
immediately  followed  by  a  marked  amelioration  in  the  symptoms.  I 
know  of  three  similar  cases  which  ended  fatally  in  which  I  have  every 
reason  to  believe  that  the  cause  of  the  disease  was  poisoning  by  sewer 
gas.  Fraukenhauser  has  related  a  curious  case  of  the  poisoning  of  four 
puerperal  women  by  sewer  gas.  In  fact,  the  whole  question  of  defec- 
tive sanitary  conditions  on  the  puerperal  state  deserves  much  more 
serious  study  than  it  has  ever  yet  received,  and  I  have  long  been  satis- 
fied that  they  have  often  much  to  do  with  certain  grave  forms  of  illness 
in  the  lying-in  state  the  origin  of  which  cannot  otherwise  be  traced.^ 

^  Since  the  above  was  written  I  have  published  a  special  paper  on  this  subject 
("Defective  Sanitation  as  a  Cause  of  Puerperal  Disease,"  ia?ice/,  February  5,  1887). 
I  append  from  it  two  cases,  as  I  think  the  diagrams  illustrating  this  source  of  danger 
may  prove  of  interest. 

The  annexed  diagram  (Fig.  197)  represents  a  bedroom  in  a  large  house  in  the  most 
fashionable  part  of  the  West  End  which  had  been  recently  taken  and  done  up  in  the 
most  costly  way.  I  attended  the  lady  of  the  house  in  her  second  confinement,  and  she 
lay  in  her  bed  at  a.  Shortly  she  developed  well-marked  septic  symptoms,  and  I  nat- 
urally investigated  the  sanitary  state  of  the  house  to  see  if  it  threw  any  light  on  their 
origin.  I  could  find  nothing  amiss.  There  was  no  bath  or  fixed  washstand  near  the 
room,  and  the  closets  were  at  a  distance,  with  the  soil-pipe  running  down  the  outside 
wall,  as  it  should  do.  It  was  not  until  some  days  afterward  that  I  discovered  tlie 
extraordinary  arrangement  depicted  in  the  diagram,  which  no  one  could  possibly  have 
suspected,  and  the  knowledge  of  which  the  patient  had  given  special  directions  should 
be  withheld  from  me.  At  b  is  represented  a  very  handsome  and  innocent-looking 
piece  of  furniture  which  seemed  to  be  a  fixed  wardrobe,  to  which  purpose  its  ends  were 
in  fact  devoted.  The  centre  door,  however,  formed  by  a  large  mirror,  opened  on  a 
concealed  water-closet  (c),  which  luxury  no  one  could  have  looked  for  in  such  a  situa- 
tion. I  subsequently  discovered  that  this  was  a  brilliant  idea  of  her  husband's,  who 
actually  had  had  a  special  soil-pipe  carried  through  the  centre  of  the  house  which 
communicated  directly  with  the  main  drain,  with  no  ventilation,  and  who  had  thus 
contrived,  at  an  enormous  cost,  to  have  a  stream  of  sewer  gas  laid  on  close  to  his  bed- 
side. And  be  it  remarked  that  builders  and  plumbers  had  carried  out  this  ingeniously 
dangerous  arrangement  without  giving  him  the  slightest  hint  that  it  was  either  un- 
usual or  perilous.  Of  course  as  soon  as  T  made  this  discovery  I  had  the  patient  removed 
to  another  room,  when  her  symptoms  soon  abated. 


608 


THE  PUERPERAL  STATE. 


Septicaemia  from  Contagion  Conveyed  from  other  Puerperal 
Patients. — Tho  last  source  from  which  septic  matter  may  1)0  ccmveved 

I  could  easily  go  on  multiplying  examples  of  this  kind,  but  I  shall  content  mvself 
with  one  more  ease,  wliiili  was  tlioroughly  worked  out  with  very  instructive  results. 
It  was  that  of  a  lady  who  was  confined  in  the  country  of  lier  first  child,  in  a  large  ;iud 
expensive  house,  newly  built,  and  supposed  to  be  supplied  with  all  the  most  perl'ect 


BEID     ROOM 


sanitary  arrangements.  There  was  nothing  particular  about  the  labor,  and  for  the  first 
ten  days  the  convalescence  left  nothing  to  be  desired.  On  the  eleventh  day  she  got  up 
and  lay  on  the  sofa  (Fig.  198,  d)  opposite  the  fire  (f),  which,  as  it  was  in  January,  was 
burning  day  and  night.  The  day  after,  although  she  had  a  headache  and  felt  poorly, 
she  again  got  up  and  lay  on  the  sofa.  The  subsequent  day,  although  feeling  very  ill, 
she  again  insisted  on  getting  up,  and  lay  on  the  sofa  at  e  in  her  husband's  dressing- 
room.  On  the  following  day  she  was  very  ill  indeed,  with  a  temperature  of  104°  and 
a  pulse  of  130,  and  I  was  summoned  to  see  her.  It  is  needless  to  say  more  of  her  ill- 
ness, which  rapidly  increased,  except  that,  feeling  satisfied  it  was  caused  by  defective 
sanitation,  I  axlvised  her  removal  to  a  house  in  the  neighborhood,  in  spite  of  the  very 
grave  symptoms  that  existed,  with  the  most  satisfactory  result,  for  within  twenty-four 
hours  her  temperature  had  fallen  and  she  rapidly  became  convalescent.  Of  course  at 
this  time  nothing  was  known  of  what  actually  existed,  but  I  was  led  to  form  this  con- 
clusion from  the  fact  that  a  number  of  the  servants  and  residents  were  sufiering  from 
sore  throats,  and  from  being  told  that  almost  every  one  who  came  to  stay  felt  ill  and 
out  of  sorts.  Subsequently  the  sanitary  state  of  the  house  was  thoroughly  investigated 
by  one  of  the  most  distinguished  sanitary  engineers  in  London,  from  whose  reports  the 
accompanying  diagram  (Fig.  198)  is  copied.  It  is  useless  to  enter  into  a  descri|)tion 
of  all  the  abominations  which  were  found  to  exist,  which,  in  a  liouse  of  the  kind,  in 
the  building  of  which  no  expense  was  spared,  were  almost  past  belief.  For  the  pur- 
pose of  my  story  it  will  suffice  to  say  that  the  smoke-test  showed  tluit  there  was  a  very 
abundant  escape  of  sewer  gas  into  both  the  bedroom  and  dressing-room,  which,  from 
the  fact  that  there  were  large  fires  burning  constantly  in  both  rooms,  pa.'ksed  in  a  con- 
tinuous current  in  the  direction  of  the  arrows.  In  addition,  the  plumbing-work  in  the 
closet  in  the  dressing-room  had  been  so  imperfectly  done  that  its  contents  found  their 
way  out  under  the  floor.  Now,  mark  how  thoroughly  and  curiously  these  facts  prove 
the  cause  of  the  disease.     The  patient  lay  in  the  bed  at  c,  which,  from  the  accident  of 


PUKRPERA  L   SEPTTCylJMrA. 


600 


is  from  a  patient  sulfci-inj;-  iVoni  piierporal  sf'[)tieremia — a  mode  of  origin 
which  has  of  late  attracted  special  attention.  That  this  is  the  explana- 
tion of  the  occasional  endemic  prevalence  of  the  disease  in  lying-in 
hospitals  can  scarcely  be  doubted.  The  theory  of  a  special  puerj^eral 
miasm  pervading  the  hospital  is  not  required  to  account  for  the  facts, 
for  there  are  a  hundred  ways  impossible  to  detect  or  avoid — on  the 
hands  of  nurses  or  attendants,  in  sponges,  bed-pans,  sheets,  or  even 
suspended  in  the  atmosphere — in  which  septic  material  derived  from 
one  patient  may  be  carried  to  another. 

The  poison  may  be  conveyed  in  the  same  manner  from  one  private 
patient  to  another.  Of  this  there  are  many  lamentable  instances 
recorded.  Thus  it  was  mentioned  by  a  gentleman  at  the  recent  discus- 
sion at  the  Obstetrical  Society  that  5  out  of  14  women  he  attended 
died,  no  other  practitioner  in  the  neighborhood  having  a  case.     This 


its  being  winter  and  the  current  of  sewer  gas  being  drawn  therefore  to  the  chimneys, 
was  quite  out  of  its  reach,  and  for  the  first  ten  days  after  her  confinement,  while  she 
remained  in  bed,  she  was  perfectly  well.  On  the  eleventh  day,  when  she  got  up,  she 
was  placed  directly  in  the  current  of  sewer  gas  at  d,  and  instantly  got  poisoned.  On 
the  twelfth  and  thirteenth  days  she  was  again  exposed  to  the  absorption  of  further  and 

Fig.  ]9S. 


more  intense  poisoning,  while  immediately  on  her  removal  to  fresh  and  uncontam- 
inated  air  all  her  thrratening  symptoms  disappeared.  Remark  also  that  there  was 
nothing  jieculiar  in  the  symptomatology,  nothing  difl^erent  from  an  ordinarv  and  rap- 
idly progressing  case  of  puerperal  septica^nia.  It  seems  to  me  that  this  instructive 
history  is  about  as  complete  a  demonstration  of  the  origin  of  puerperal  disease  from 
defective  sanitation  as  any  one  could  possibly  desire,  and  I  can  see  no  fiawin  tlie  chain 
of  evidence. 

,39 


610  THE  PUERPERAL  STATE. 

origin  of  the  disease  was  clearly  pointed  ont  by  Gordon'  toward  the 
end  of  last  centnry,  w'ho  stated  that  he  himself  "  was  the  means  of  car- 
rying the  infection  to  a  great  number  of  women,"  and  he  also  traced 
the  spread  of  the  disease  in  the  same  way  in  the  practice  of  certain 
raidwives.  In  some  remarkable  instances  the  unhappy  ])roperty  of 
carrying  contagion  has  clung  to  individuals  in  a  way  which  is  most 
mysterious,  and  which  has  led  to  the  supposition  that  the  whole  system 
becomes  saturated  with  the  poison.  One  of  the  strangest  cases  of  this 
kind  was  that  of  Dr.  Rutter  of  Philadelphia,  which  caused  much  dis- 
cussion. He  had  45  cases  of  puerperal  septicaemia  in  his  own  practice 
in  one  year,  while  none  of  his  neighbors'  patients  were  attacked.  Of 
him  it  is  related:  "Dr.  Rutter,  to  rid  himself  of  the  mysteri(jus 
influence  which  seemed  to  attend  upon  his  practice,  left  the  city  for  ten 
days,  and  before  waiting  on  the  next  parturient  case  had  his  hair 
shaved  off  and  put  on  a  wig,  took  a  hot  bath,  and  changed  every  arti- 
cle of  his  apparel,  taking  nothing  with  him  that  he  had  worn  or  carried 
to  his  knowledge  on  any  former  occasion ;  and  mark  the  result !  The 
ladv,  notwithstanding  that  she  had  an  easy  parturition,  was  seized  the 
next  day  w'ith  childbed  fever,  and  died  on  the  eleventh  day  after  the 
birth  of  the  child.  Two  years  later  he  made  another  attempt  at  self- 
purification,  and  the  next  case  attended  fell  a  victim  to  the  same  dis- 
ease." Xo  wonder  that  Meigs,  in  commenting  on  such  a  history,  refused 
to  believe  that  the  doctor  carried  the  poison,  and  rather  thought  "that 
he  was  merely  unhappy  in  meeting  with  such  accidents  through  God's 
providence."  It  appears,  however,  that  Dr.  Rutter  was  the  subject  of 
a  form  of  oz?ena;  and  it  is  quite  obvious  that  under  such  circumstances 
his  hands  coukf  never  have  been  free  from  septic  matter.-  This  obser- 
vation is  of  peculiar  interest  as  showing  that  the  sources  of  infection 
may  exist  in  conditions  difficult  to  suspect  and  impossible  to  obviate,  and 
it  affords  a  satisfactory  explanation  of  a  case  which  was  for  years  consid- 
ered puzzling  in  the  extreme.  It  is  quite  possible  that  other  similar 
cases,  of  which  many  are  on  record,  although  none  so  remarkable,  may 
possiblv  have  depended  on  some  similar  cause  personal  to  the  medical 
attendant. 

The  sources  of  septic  poison  being  thus  multifarious,  a  few  words  may 
be  said  as  to  the  mode  in  which  it  may  be  conveyed  to  the  patient. 

Mode  in  "which  the  Poison  may  be  Conveyed  to  the  Patient. — 
As  on  the  view  of  puerperal  septicseraia  which  seems  most  to  agree 
with  recorded  facts,  the  poison,  from  whatever  source  it  may  be  derived, 
must  come  into  actual  contact  with  lesions  of  continuity  in  the  genera- 
tive tract,  it  is  obvious~fh"?iT:  one  method  of  conveyance  may  be  on  the 
hands  of  the  accoucheur.     That  this  is  a  possibility,  and  that  the  dis- 

^  See  Lectures  on  Puerperal  Fever,  by  Robert  J.  Lee,  ]\I.  D. 

*This  is  stated  on  tbe  authority  of  an  obstetrical  contemporary  of  Dr.  Rutter.  i.See 
Amer.  .Town,  of  Med.  Science,  1875,  vol.  Ixix.  p.  474  (Minor).  I 

The  author  quotes  from  the  editor.  Dr.  Rutter  had  an  ozrena  which  in  time  much 
disfigured  him  from  its  effect  upon  tlie  contour  of  his  nose.  He  was  unfortunately 
inoculated  in  his  index  finser  from  a  patient,  and  neglected  the  ])ustule.  He  liad  iir> 
cases  of  puerperal  septicaemia  in  four  years  and  nine  months,  with  IS  deaths.  The 
question  of  Dr.  Meigs,  who  was  a  non-contagionist  in  regard  to  puerperal  peritonitis, 
was  remarkably  appo.site  -  "Did  he  distil  a  subtle  essence  which  he  carried  with 
him  ?  " — Harris,  note  to  3d  American  edition. 


PUERPERAL  SEPTICEMIA.  01 1 

ease  has  often  been  uiiliappily  conveyed  in  tin's  way,  no  one  can  doubt. 
Still,  it  would  be  unfair  in  the  extreme  to  conclude  that  this  is  the  only 
way  in  which  infection  may  arise.  In  town  practice  especially  there 
are  many  other  ways  in  which  septic  matter  may  reach  the  patient.  The 
nurse  may  be  tlie  means  of  communication,  and  if  she  have  been  in 
contact  with  septic  matter  she  is  even  more  likely  than  the  medical 
attendant  to  convey  it  when  washing  the  genitals  during  the  first  few 
days  after  delivery,  the  time  that  absorption  is  most  apt  to  occur. 
Barnes  relates  a  whole  series  of  cases  occurring  in  a  suburb  of  London 
in  the  practice  of  different  practitioners,  every  one  of  which  was 
attended  by  the  same  nurse.  Again,  septic  matter  may  be  carried  in 
sponges,  linen,  and  other  articles.  What  is  more  likely,  for  example, 
than  that  a  careless  nurse  might  use  an  imperfectly  washed  sponge  on 
which  discharge  has  been  allowed  to  remain  and  decompose  ?  Xor  do 
I  see  any  reason  to  question  the  possibility  of  infection  from  septic 
matter  suspended  in  the  atmosphere ;  and  in  lying-in  hospitals,  where 
many  women  are  congregated"  Together,  there  can  be  little  doubt  that 
this  is  a  common  origin  of  the  disease.  It  is  certain,  whatever  view 
we  may  take  of  the  character  of  the  septic  material,  that  it  must  be  in 
a  state  of  very  minute  subdivision,  and  there  is  no  theoretical  difficulty 
in  the  assumption  of  its  being  conveyed  by  the  atmosphere. 

Conduct  of  the  Practitioner  in  Relation  to  the  Disease. — This 
question  naturally  involves  a  reference  to  the  duty  of  those  who  are 
unfortunately  brought  into  contact  with  septic  matter  in  any  form, 
either  in  a  patient  suffering  from  puerperal  septicaemia,  zymotic  disease, 
or  offensive  discharges.  The  practitioner  cannot  always  avoid  such  con- 
tact, and  it  is  practically  impossible  to  relinquish  obstetric  work  every 
time  that  he  is  in  attendance  on  a  case  from  which  contagion  may  be 
carried.  jS^or  do  I  believe,  especially  in  these  days  when  the  use  of 
antiseptics  is  so  well  imderstood,  that  it  is  essential.  It  was  otherwise 
when  antiseptics  were  not  employed,  but  I  can  scarcely  conceive  any 
case  in  which  the  risk  of  infection  cannot  be  prevented  by  proper  care. 
The  danger  I  believe  to  be  chiefly  in  not  recognizing  the  possible  risk, 
and  in  neglecting  the  use  of  proper  precautions.  It  is  impossible, 
therefore,  to  urge  too  strongly  the  necessity  of  extreme  and  even  exag- 
gerated care  in  this  direction.  The  practitioner  should  accustom  him- 
self, as  much  as  possible,  to  use  the  left  hand  only  in  touching  patients 
suffering  from  infectious  diseases,  as  that  which  is  not  used,  under  ordi- 
nary circumstances,  in  obstetric  manipulations.  He  should  be  most 
careful  in  the  frequent  employment  of  antiseptics  in  washing  his  hands, 
such  as  Condy'sfluid,  carbolicacid,  or  the  1-iu-lOOO  solution  of  perchloride 
of  mercury.  Clothing  should  be  changed  on  leaving  an  infectious  case. 
Much  more  care  than  is  usually  practised  should  be  taken  by  nurses,  espe- 
cially in  securing  perfect  cleanliness  in  everything  brought  into  contact 
with  the  patient.  When,  however,  a  practitioner  is  in  actual  and  con- 
stant attendance  on  a  case  of  puerperal  septicaemia,  when  he  is  visiting 
his  patient  many  times  a  day,  especially  if  he  be  himself  washing  out 
the  uterus  with  antiseptic  lotions,  it  is  certain  that  he  cannot  deliver 
other  patients  with  safety,  and  he  should  secure  the  assistance  of  a 
brother-practitioner,  although  there  seems  no  reason  why  he  should  not 


G12  THE  PUERPERAL  STATE. 

visit  women  already  coufined  in  whom  he  has  not  to  make  vaginal 
examinations. 

Prophylaxis  of  Septicaemia. — If  tlie  views  here  inculcated  as  to 
the  nature  of,  and  mode  of  infection  in,  puerperal  septicemia  be  cor- 
rect, it  is  obvious  that  much  may  be  done  in  the  way  of  prophylaxis. 
A  perfectly  aseptic  management  of  puerperal  women  is  practically 
impossible.  In  most  lying-in  institutions  very  rigid  rules  are  now 
laid  down  to  prevent  the  possibilit}'  of  infectiye  matter  being  conveyed 
to  the  patient  either  on  the  hands  of  the  attendants  or  on  instrupjents, 
napkins,  and  the  like,  and  with  the  most  satisfactory  results.  As  the 
risk  is  much  greater  when  lying-in  women  are  collected  together,  such 
precautions,  which  this  is  not  the  place  to  discuss,  are  absolutely  indi- 
cated. They  are  not,  however,  easily  applicable  in  ordinary  private 
practice,  but  there  are  certain  simple  precautious  which  every  one  might 
adopt  without  trouble  which  will  materially  lessen  the  risk  of  septic 
poisoning.  Amongst  these  may  be  indicated  the  use  of  antiseptic 
lotions,  with  which  the  practitioner  and  nurse  should  always  wash  their 
hands  before  attending  any  case  or  touching  the  genital  organs ;  the  use 
of  carbolized  vaseline,  1  in  8,  for  lubricating  the  fingers,  catheter,  for- 
ceps, etc. ;  syringing  out  the  vagina  night  and  morning  with  diluted 
Coudy's  fluid;  rigid  attention  to  cleanliness  in  bedding,  napkins,  etc. 
Precautions  such  as  these,  although  they  may  appear  to  some  frivolous 
and  useless,  indicate  a  recognition  of  danger  and  an  endeavor  to  re- 
move it,  and  if  they  were  generally  inculcated  on  nurses  (see  note, 
p.  560)  and  others,  might  go  far  to  prevent  the  occurrence  of  septic 
mischief. 

Nature  of  the  Septic  Poison.— ^As  to  the  precise  character  of  the  septic 
jpoison — although  of  late  much  has  been  said  about  it,  and  there  is  good 
/reason  to  believe  that  further  research  may  throw  light  on  this  obscure 
(subject — too  little  is  known  to  justifH^  any  positive  statement.)  The 
researches  of  Heiberg,  Von  Eecklinghausen,  Steurer,  and  others  have 
shown  that  in  puerperal  septicaemia,  as  in  surgical  fever,  eiysipelas,  and 
other  infectious  diseases,  micrococci  in  large  numbers  may  be  traced 
passing  between  the  muscular  and  connective-tissue  fibres,  through  the 
lymphatics,  and  thus  into  the  general  circulation,  and  that  they  may  be 
found  in  various  organs  and  pathological  products.  More  recently, 
Frjinkel  isolated  from  a  number  of  cases  a  chain-forming  micrococcus, 
which  he  at  first  regarded  as  specific,  and  named  it  the  Streptococcus 
puerperalis.  Subsequently  he  satisfied  himself  of  its  identity  witli  a 
similar  micro-organism  in  pus.  Winkel  also  cultivated  a  sti'eptococcus 
from  a  case  of  puerperal  peritonitis.  It  produced  an  erysipelatous  rash 
in  the  ear  of  a  rabbit,  and  was  similar  in  its  characters,  both  morpho- 
logically and  in  artificial  cultivations,  to  the  streptococcus  found  in 
erysipelas.  Gushing  found  streptococci  in  endometritis  diphtheritica 
and  in  secondary  puerperal  inflammation,  and  Baumgarten,  Bumm, 
Pfannestiel,  and  others  have  recorded  similar  observations.  Pfannestiel 
investigated  four  cases  of  puerperal  septicaemia  with  diphtheritic  end.o- 
metritis  and  purulent  peritonitis,  and  he  concluded  that  a  specific  micro- 
organism could  not  be  differentiated  in  puerperal  fever.  In  his  opinion 
the  streptococci  from  pus,  from  erysipelas,  and  diphtheritic  affections  of 


PUERPERAL  SEPTICAEMIA.  613 

the  pharynx  had  all  the  power  of  setting  up  puerperal  septictcniia. 
These  observations  are  of  niueh  importance,  as  tending  to  confirm  by 
scientific  observation  the  intimate  relation  between  these  various  forms  of 
disease  which  has  long  been  believed  to  exist.     It  may  be  taken  as  certaiiD 
that  streptococci  bear  an  intimate  and  important  relation  to  the  disease,] 
but  wheffiei"  they  themselves  form  the  septic  matter  or  carry  it,  or/ 
whether  they  are  mere  accidental  concomitants  of  the  jiysemic  processes,' 
it  is  impossible,  in  the  present  state  of  our  knowledge,  to  decide.     ■ 

Channels  of  Diffusion. — Passing  on  to  the  channels  of  diffusion 
through  which  the  septic  matter  may  act,  we  have  to  consider  its 
effects  on  the  structures  with  which  it  is  brought  into  contact  and  the 
mode  in  which  it  may  infect  the  system  at  large;  and  this  will  include 
a  consideration  of  the  pathological  phenomena. 

Local  changes  consequent  on  the  absorption  of  the  poison  are 
pretty  constant,  and  of  these  we  may  form  an  intelligible  idea  by  think- 
ing of  them  as  similar  in  character  and  causation  to  those  which  we 
have  the  opportunity  of  studying  when  septic  matter  is  applied  to  a 
wound  open  to  observation,  as,  for  example,  in  cases  of  blood-poison- 
ing following  a  dissection  wound.  Distinct  traces  of  local  action  are 
not  of  invariable  occurrence,  and  in  some  of  the  worst  class  of  cases, 
when  the  amount  of  septic  matter  is  great  and  its  absorption  rapid, 
death  may  occur  after  an  illness  of  short  duration  but  great  intensity, 
and  before  appreciable  local  changes,  either  at  the  site  of  absorption 
or  in  the  system  at  large,  have  had  time  to  develop  themselves.  The  ^^ 
fact  that  puerperal  fever  may  prove  fatal  without  leaving  any  tangible  I 
post-mortem  signs  has  often  iDcen  pointed  out,  such  cases  most  fre-  / 
quently  occurring  during  the  endemic  prevalence  of  the  disease  in  ' 
lying-in  hospitals.  There  can  be  little  doubt,  however,  that  in  such 
cases  of  intense  septicsemia  marked  pathological  changes  exist  in  the 
form  of  alterations  of  the  blood  and  degenerations  of  tissue,  but  not 
•of  a  character  which  can  be  detected  by  an  ordinary  post-mortem 
examination.  In  the  great  majority  of  cases  indications  of  the  disease 
exist  at  the  site  of  absorption.  These  are  described  by  pathologists 
as  identical  in  their  character  with  the  inflammatory  oedema  which 
occurs  in  connection  with  phlegmonous  erysipelas.  (If  lacerations  exist 
in  the  cervix  or  vagina,  they  take  on  unhealthy  action,  their  edges  swell, 
and  their  surface  becomes  covered  with  a  yellowish  coat  similar  in  appear- 
ance to  diphtheritic  membrane.!  The  mucous  membrane  of  the  uterus 
is  also  generally  found  to  be  affected,  and  in  a  degree  varying  with  the 
intensity  of  the  local  septic  process.  There  is  evidence  of  severe 
endometritis,  and  very  frequently  the  whole  lining  of  the  uterus  is 
proJoundly  altered,  softened,  covered  with  patches  of  diphtheritic 
deposit,  and  it  may  be  in  a  state  of  general  necrosis.  /In  the  severer 
cases  these  changes  affect  the  muscular  tissue  of  the  uterus,  which  is 
found  to  be  swollen,  soft,  imperfectly  contracted,  and  even  partially 
necrosed — a  condition  which  is  likened  by  Heiberg  to  hospital  gan- 
grene. The  connective  tissue  surrounding  the  generative  tract  is  also 
swollen  and  oedematous,  and  the  inflammation  may  in  this  way  reach 
the  peritoneum,  although  peritonitis,  so  often  observed  in  puerperal 
septicemia,  does  not  necessarily  depend  on  the  direct  transmission  of 


614  THE  PUERPERAL  STATE. 

inflammation  from  the  pelvic  connective  tissue,  but  it  is  more  often  a 
secondary  phenomenon. 

The  channels  through  ■which  general  systemic  infection  may 
supervene  are  the  lymphatics  and  the  venous  sinuses,  the  former  being 
by  far  the  most  im]3ort"ant.  Recent  researches  have  shown  tlie  great 
number  and  complexity  of  the  lymphatics  in  connection  with  the  pelvic 
viscera,  and  marked  traces  of  the  absorption  of  septic  matter  are  almost 
always  to  be  found,  except  in  those  very  intense  cases  already  alluded 
to  in  which  mo  appreciable  post-mortem  signs  are  discoverable.  The 
septic  matter  is  probably  absorbed  from  the  lymph -spaces  abounding  in 
the  connective  tissue  and  carried  along  the  lymphatic  canals  to  the  near- 
est glands.  (The  result  is  inflammation  of  their  coats  and  thrombosis  of 
their  contents,  which  may  be  seen  on  section  as  a  creamy  purulent  sub- 
stanceA  (The  absorption  of  septic  material  may,  as  Virchow^  has  shown, 
be  delayed  by  the  local  changes  produced  in  the  lymphatics  and  in  the 
glands  with  which  tney  communicate,  Avhich  are  therefore  conservative 
in  their  action  ;  and  the  further  progress  of  the  case  may  in  this  way  be 
stopped  and  local  inflammation  alone  result,  such  cases  being  believed 
bv  Heiberg  to  be  examples  of  abortive  pygemia.  On  the  other  hand, 
the  free  septic  material  may  be  too  abundant  and  intense  to  be  so  arrested ; 
it  may  pass  on  through  the  lymph-canals  and  glands  until  it  reaches  the 
blood-current  through  the  thoracic  duct,  and  so  2)roduce  a  general  blood- 
infection.  This  mode  of  absorption  of  septic  matter,  and  the  tendency 
of  the  glands  to  arrest  its  further  progress,  serve  to  explain  the  pro- 
gressive character  of  many  cases  in  which  fresh  exacerbations  seem  to 
occur  from  time  to  time,  since  fresh  quantities  of  poison,  generated  at 
its  source  of  origin,  may  be  absorbed  as  the  case  progresses.  The 
uterine  veins  are  sujDposed  by  D'Espine  to  be  the  channel  of  absorp- 
tion in  the  intense  form  of  disease  which  proves  fatal  very  shortly  after 
delivery,  too  soon  for  the  more  gradual  process  of  lymphatic  absorption 
to  have  become  established.  It  is  evident  that  the  veins  are  not  likely 
to  act  in  this  Avay,  since  they  must,  under  ordinary  circumstances,  be 
completely  occluded  by  thrombi,  otherwise  hemorrhage  would  occur. 
If,  how^ever,  uterine  contraction  be  incomplete,  the  occlusion  of  the  ven- 
ous sinuses  may  be  imperfect,  and  absorption  of  septic  material  through 
them  may  then  take  place.  Some  writers  have  laid  great  stress  on 
imperfect  uterine  contraction  in  predisposing  to  septicemia,  and  its 
influence  may  thus  be  well  explained.  The  veins  may  bear  an  import- 
ant part  in  the  production  of  septiceemia,  independent  of  the  direct 
absorption  of  septic  matter  through  them,  by  means  of  the  detachment 
of  minute  portions  of  their  occluding  thrombi  in  the  form  of  emboli. 
If  phlegmonous  inflammation  occur  in  the  immediate  vicinity  of  the 
veins,  the  thrombi  they  contain  may  become  infected.  AYhen  once 
blood-infection  has  occurred  by  any  of  these  channels,  general  septi- 
caemia, the  so-called  puerperal  fever,  is  developed. 

Four  Principal  Types  of  Pathological  Change. — The  variety  of 
pathological  phenomena  found  on  post-mortem  examination  has  had 
much  to  do  with  the  prevalent  confusion  as  to  the  nature  of  the  dis- 
ease. This  has  resulted  in  the  description  of  many  distinct  forms  of 
puerperal  fever,  the  most  remarked  pathological  alteration  having  been 


PUERPERAL  SEPTICEMIA.  615 

taken  to  be  the  essential  element  of  the  disease.  As  a  matter  of  fact, 
there  is  no  doubt  that  various  types  of  pathological  change  are  met 
with.  Heiberg  describes  four  chief  classes  which  are  by  no  means 
distinctly  separated  from  one  another,  are  often  found  simultaneously 
in  the  same  subject,  and  are  certainly  not  to  be  distinguished  by  the 
symptoms  during  life. 

(Of  these  thefirgtjg^the  dass  of  cases  in  which  no  appreciable  morbid 
phenomena  are~%und  after  death.  )  This  formidable  and  fatal  form  of 
the  disease  has  long  been  well  known,  and  is  that  described  by  some  of 
our  authors  as  adynamic  or  malignant  puerperal  fever.  It  is  the  variety 
which  was  so  prevalent  in  our  lying-in  hospitals,  and  which  Ramsbotham^ 
talks  of  as  being  second  only  to  cholera  in  the  severity  and  suddenness 
of  its  onset  and  in  the  rapidity  with  which  it  carried  off  its  victims.  It 
is  quite  erroneous  to  suppose  that  the  existence  of  pathological  changes 
in  this  form  of  disease  has  never  been  recognized.  Even  with  the 
coarse  methods  of  examination  formerly  used,  the  occurrence  of  a  fluid 
and  altered  state  of  tlie  blood  and  ecchymoses  in  connection  with  vari- 
ous organs — especially  the  lungs,  spleen,  and  kidneys — were  noticed  and 
specially  described  by  Copland  in  his  Dictionary  of  Medicine.  More 
recently  it  has  been  clearly  proved  by  the  microscope  that  there  exist, 
in  addition,  the  commencement  of  inflammation  in  most  of  the  tissues, 
shown  by  cloudy  swellings  and  granular  infiltration  and  disintegration 
of  the  cell-elements,  proving  that  the  blood,  heavily  charged  with  septic 
matter,  had  set  up  morbicl  action  wherever  it  circulated,  the  patient 
succumbing  before  this  had  time  to  develop. 

In  the  second  type,  and  that  perhaps  most  commonly  met  with,  the 
morbid  changes  are  more  frequently  found  in  the  serous  membranes,  in 
the  pleura,  in  the  pericardium,  but  above  all  in  tEe^eriitoneum,  the 
alterations  in  which  have  long  attracted  notice,  and  have  been  taken 
by  many  writers  as  proving  peritonitis  to  be  the  main  element  of  the 
disease.  Evidences  of  more  or  less  peritonitis  are  very  general.  In  the 
more  severe  cases  there  is  little  or  no  exudation  of  plastic  lymph,  such 
as  is  found  in  peritonitis  unassociated  with  septicaemia.  There  is  a 
greater  or  less  quantity  of  brownish  serum  only,  the  coils  of  intestine, 
distended  with  flatus  and  highly  congested,  being  surrounded  by  it. 
More  often  there  are  patchy  deposits  of  fibrinous  exudation  over 
many  of  the  viscera,  the  fundus  uteri,  the  under  surface  of  the  liver, 
and  the  distended  intestines.  There  is  then  also  a  considerable  quantity 
of  sero-purulent  fluid  in  the  abdominal  cavity.  The  pleural  cavities 
may  also  exhibit  similar  traces  of  inflammatory  action,  containing 
imperfectly  organized  lymph  and  sero-purulent  fluid.  Schroeder  states 
that  pleurisy  is  more  often  the  direct  result  of  transmission  of  inflam- 
mation through  the  substance  of  the  diaphragm  or  lung  than  a  secondary 
consequence  of  the  septicaemia.  In  like  manner,  evidences  of  pericarditis 
may  exist,  the  surface  of  the  pericardium  being  highly  injected  and  its 
cavity  containing  serous  fluid.  Inflammation  of  the  synovial  mem- 
branes of  the  larger  joints,  occasionally  ending  in  suppuration,  is  not 
uncommon,  and  may  probably  be  best  included  under  this  class  of 
cases. 

In  the  third  type  the  mucous  membranes  appear  to  bear  the  brunt 


616 


THE  PUERPERAL  STATE. 


of  the  disease.  The  pathulogical  changes  are  most  marked  iu  the 
mucous  memljrane  liuing  the  intestiues,  which  is  highly  congested  and 
evecTurcerated  in  patches,  with  numerous  small  spots  of  blood  extra va- 
sated  in  the  submucous  tissue.  Similar  small  apoplectic  eifusions  have 
been  observed  iu  the  substance  of  the  kidneys  and  under  the  mucous 
membrane  of  the  bladder.'  Pneumonia  is  of  common  occurrence.  In 
most  cases  it  is  probably  secondary  to  the  impaction  of  minute  emboli 
iu  the  smaller  branches  of  the  pulmonary  artery,  but  it  may  doubtless 
arise  from  independent  inflammation  of  the  lung-tissue,  and  will  then 
be  included  in  a  class  of  cases  now  under  consideration. 

Fig.  199. 

Name.  A.  S ,  age  30;  confined  Feb.  27, 1879;  died  March  10. 


TIME 

m:e 

m'e 

m|e 

M|E 

M!E 

M 

E 

M   E 

ME 

M  E 

- 

E 

-^ 

E 

^  E 

1 

1 

1 

1 

107 

lOb 

lOf 

joi 

z    202 

I 

-            0 

NORM.TEM. 
OF  BODY 

g8° 



' 

I  _ 





1 

, 







H- 

i 

—  — 

— i — 

— 

— 

— 

— 

' — 

— 

— 

— 

1 

^- 

1 

1 

1 

1 

— 

j 

1 

_j 

1 

1 

1 

1 

I 

j 

— 



1 

1 

1 

1 

[ 

i 

1 

1 

' 

— ^_ 

— 1— 

~l~ 

— — 

—  — 

— 1— 

H— 

— i~ 

~i — 

— 

—  - 

1 

— — 



— ]— 

A 

— — 

— 

, 

\- 

^= 

\_ 

— 

V 

A^= 

—  — 

— 



—  — 

Y 

-/il- 

1 

-^ 

-  1 

\ 

■    ^ 

i 

1  ' 

• 

_  , 

./^ 

1 

~~ 

.^ 

1  ■ 

-^ 

— 

__^ 

K 

f\ 

_!_ 

l-l- 

\ 



l\ 

/  N 

i 

— 

— 

r 

'— V. 

■r-y 

i 

— ]— 

— 

■ 

E 

% 

=i= 

— 

1 

■ 

1 

1 

- 

— 

- 

-H 

Y 

j 

i 

1 

— :  — 

\^ 

r 

\ 

1 

--I 

- 

1 

— 

— 

-I— 

— 1- 

— 1— 

^^ 

— 

—  - 

t-i — 

1 

1 

— ;— 

\ 

— 1— 

— 

— 

-:  = 

/ 

\ 

— I— 

— j— 

1 

— 



1 

"in 

E 

e: 

1  / 

1 

— 

-J- 

y — 

— 1— 

— ^ 

— 

-i- 

■ 

■ 



: 

! 

_ 



=  _ 

E'E 

1 

i 

i 

1 

1 

1 

— 

I 

1 

^ 

— 

— i— 

—!— 

d- 

^— 

-,- 

=  = 

— - 

=1=- 

' 

^- 

— i— 

-i— 

— — 

— |— 

— 

— 

— !- 

— I- 

-;— - 

— 

t- 

1 

EE 

=  = 

EE 

^^ 

~ 

— 

— 

— 

— 

— 

— 

— 

— 

— 

1 

1 

DAY  OF 

DIS. 

1ST. 

2nd. 

3RD. 

4TH. 

5TH. 

6TH. 

7TH. 

8TH- 

9TH. 

10TH 

ITH. 

PULSE 

"H^ 

\126 

126\ 

^ 

"J^ 

^>\ 

;v 

;^ 

\ 

\ 

\, 

DATE 

27 

28 

Marl 

2 

3 

4 

5 

6 

7 

8 

9 

10 

The  fourtli  class  of  pathological  phenomena  are  those  which  are  pro- 
duced chiefl^n^n'  the  impact ipn  of  minute  infected  emboji  in  small  ves- 
sels in  various  parts  of  the  body.  These  are  the  cases  which  most  closely 
resemble  surgical  pyaemia  both  in  their  symptoms  and  post-mortem 
signs,  and  which  by  many  writers  are  described  under  the  name  of 
"  puerperal  pysemia."  The  dependence  of  puerperal  fever  on  phlebitis 
of  the  uterine  veins  was  a  favorite  theory,  and  in  a  large  proportion  of 
cases  the  coats  of  the  veins  show  signs  of  inflammation,  their  canals 
being  occupied  with  thrombi  in  a  more  or  less  advanced  state  of  disin- 
tegration. The  mode  in  which  these  thrombi  may  become  infected  has 
been  shown  by  Babnoff,  who  has  proved  that  leucocytes  may  penetrate 


P IJ ERF  ERA  L  SEPTICEMIA . 


617 


the  coats  of  the  vein,  aucl,  eiiterhig  its  contained  coagulum,  may  set  up 
disintegration  and  suppuration.  This  observation  brings  these  pysemic 
forms  of  disease  into  close  relation  with  septiceemia,  such  as  we  have 
been  studying,  and  justifies  the  conclusion  of  Verneuil  that  purulent 
infection  is  not  a  distinct  disease,  but  only  a  termination  of  septicaemia, 
with  which  it  ought  to  be  studied.  We  have,  moreover,  to  differentiate 
these  results  of  embolism  from  those  considered  in  a  subsequent  chap- 
ter, the  characteristic  of  these  cases  being  the  infected  nature  of  tiie 
minute  emboli.  Localized  inflammations  and  abscesses,  from  the 
impaction  of   minute  capillary  emboli,  are    found  in  many  parts  of 


Fig.  200. 


Mrs.  D ,  age  25;   confined  May  1,  1879.    Puerperal  septiceemia ;  recovery.    An  untrapped 

pipe,  communicating  with  sewer,  was  found  in  bath  close  to  this  patient's  bed. 


TIME 

M 

E 

M 

E 

M 

E 

M 

^ 

M 

E 

M   E 

ME 

M|E 

M  E 

m|e 

M 

E 

7 

E 

M 

E 

M 

E 

1^ 

E 

1 

1 

i 

o 
TO? 

job° 

IOJ° 

104° 

i  103° 

I 

<                                                Q 

-^    lOI 

UI 

c 

2    100 

•s. 

'^    09° 

NORM.TEM 
OF  BODY 

95= 

. 

— 

1 

1 

-L 

o; 

-J 

1 

■i- 

- 

— 

— 

— 

— 

— 

1 

i 

— 

— 

— 

— 

-J 

— 

— 

L 

< 

— 

- 

— 

— 

L— 

5-L 

— 

_Q. 

— 

^ 

— 

L 

— 

>lO~ 

— 

— 

» 

— 

~'i5- 

v' — 

— 

— 

-Q. 

i^ 

— 

■i^ 

— 

- 

-J 

in' 

— 

— 

-^ 

-y^ 

— 

^ 

.3 

<" 

— 

— 

— 

- 

fTl 

n  ' 

7 

H 

1 

Q. 

IT 

- 

— 

.q:. 

^ 

A 

-s- 

# 

V 

— 

K 

\  1- 

A 

^ 

ii 

'  \ 

'  \ 

iij 

J 

' 

fT 

I 

■ 

\ 

v. 

1 

'\ 

1 

1 V 

\ 

K 

1 

1  K 

\ 

\ 

1 1 

\ 

i  ' 

'  f  1 

1 

1 

1 

\  , 

\i 

\ 

/  \ 

j 

1 

f 

W 

\: 

7  \ 

j 

fl 

1 

I 

« 

\ 

1 

1   ' 

1    1 

/l 

1 

1 

1 

\ 

1  ( 

1    / 

1  I 

\ 

W 

1 

I     '  i 

I 

/    1 

1 

1 

w 

' 

\     \r 

1 

I 

y 

\/' 

- 

r 

\/ 

/i 

1 

1/ 

• 

/  ! 

y 

1 

1 

1 

1 

1 

f\ 

_ 

^ 



I 

/ 

V 

■ 

/ 

/ 

) 

DAY  OF 
DIS. 

1ST. 

2ND. 

3RD. 

4TH. 

5TH. 

6TH. 

7th. 

8th. 

9th. 

10TH 

11TH 

12TH. 

13T« 

14TH 

PULSE 

102 

88 

100 

108 

DATE 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

the  body  ;  most  frequently  in  the  lungs,  then  in  the  kidneys,  spleen,  and 
liver,  and  also  in  the  muscles  and  connective  tissues.  Pathologists  are 
by  no  means  agreed  as  to  the  invariable  dependence  of  these  on  embol- 
ism, nor  is  it  possible  to  prove  their  origin  from  this  source  by  post- 
mortem examination.  Some  attribute  all  such  cases  to  embolism; 
others  think  that  they  may  be  the  results  of  primary  septicemic  inflam- 
mation. It  has  been  proved  by  AYeber  that  minute  infected  emboli 
may  pass  through  the  lung-capillaries ;  and  this  disposes  of  one  argu- 
ment against  the  embolic  theory  based  on  the  supposed  impossibility  of 
their  passage.     It  is  probable  that  both  causes  may  operate,  and  that 


618 


THE  PUERPERAL  STATE. 


Fig.  201. 

Mrs.  P ,  age  21 ;  labor  natural ;  confined 

May  22,  1S80.  A  piece  of  decomposed 
membrane  the  size  of  hand  washed  out 
of  her  uterus  at  first  intra-uterine  injec- 
tion ;  rapid  recovery. 


localized  iiiflaniniatious  occurring  a  short  time  after  delivery  are  directly 
produced  by  the  infected  blood,  while  those  occurring  after  the  lapse  of 
some  time,  as  in  the  second  or  third  week,  depend  upon  embolism. 

Description  of  the  Disease. — From  what  has  been  said  as  to  the 
mode  of  infection  in  puerperal  septicaemia,  and  as  to  the  very  various 
pathological  changes  which  accompany  it,  it  will  not  be  a  matter  of 
surprise  to  find  tiiat  the  symptoms  are  also  very  various  in  different 
cases.  This  can  readily  be  explained  by  the  amount  and  virulence  of 
the  poison  absorbed,  the  channels  of  infection,  and  the  organs  which 

are  chiefly  implicated  ;  but  it  renders 
it  very  difficult  to  describe  the  dis- 
ease satisfactorily. 

The  symptoms  generally  show 
themselves  within  two  or  three  days 
after  delivery.  As  infection  most 
often  occurs  during  labor,  or  in  cases 
which  are  autogenetic  within  a  short 
time  afterward,  and  before  the  lesions 
of  continuity  in  the  generative  tract 
have  commenced  to  cicatrize,  it  can 
be  understood  why  septicaemia  rarely 
commences  later  than  the  fourth  or 
fifth  day. 

In  the  great  majority  of  cases  the 
disease  begins  insidiously.  There  are^ 
generally,  some  chilliness  and  rigor, 
but  by  no  means  always,  and  even 
when  present  they  frequently  escape 
observation  or  are  referred  to  some 
transient  cause.  The  first  symptom 
which  excites  attention  is  a  rise  iii  the 
pulse,  M'hich  may  vary  from  100  to 
Mti  or  more  according  to  the  severity 
of  the  attack,  and  the  thermometer 
will  also  show  that  the  tempera tiu'e 
is  raised  to  102°,  or  in  bad  cases  to 
X0'4°  or  106°r  Still,  it  must  be  borne 
in  mind  that  both  the  pulse  and  tem- 
perature may  be  increased  in  the  puer- 
peral state  from  transient  causes,  and  do  not  of  themselves  justify  the 
diagnosis  of  septicsemia. 

In  the  more  intense  class  of  cases,  in  which  the  whole  system  seems 
overwhelmed  with  the  severity  of  the  attack,  the  disease  progresses  with 
great  rapidity,  and  often  without  any  appreciable  indication  of  local 
complication.  The  pulse  is  very  rapid,  small,  and  feeble,  varying  from 
120  to  140,  and  there  is  generally  a  temperature  of  103°  to  104°.  In 
the  worst  form  of  cases  the  temperature  is  steadily  high,  witliout  marked 
remissions.  (See  Figs.  204,  199,  and  205.)  There  may  be  little  or  no_ 
pain  or  tliere  may  be  slight  tenderness  on  pressure  over  the  abdomen  or 
liTerus,  and  as  the  disease  j)rogresses  the  intestines  get  largek^disteided 


TIME 

rM- 

E 

M 

E 

U 

E 

M    E 

M 

F 

M 

E 

M 

E 

lof 

0 

104 
103 

1    103 

I 

<  ° 

Ji   JOI 

<  100 

Q. 

E 

«ORM.TEM. 
Ofi  BODY 

<j8 

M' 

^ 

, 



<tu 

—9- 

ySL_ 







— 

^ 

^^tT 

nnr 

cr— 

— 

' — 

o 

<-l 

-'^-FT— 

uj|-li 

H 

-f-ipr 

1  -^ 

■   1 

- 

1   K-\ 

rr  1 

1 

^ 

1  — 

O  1 

1 

— 1 — 

f 

w 

/ 

y 

- 

1 

J 

r 

1 

1 

/ 

1 

1 

". 

n    X 

1 

I 

r,  1 

1 

— 

'^ 

1 

1 

/ 

I 

i 

1 

— 

\ 

\ 

— 

:5 

l?y 

1 

1 

1 

— 

— 

— 

^ 

-a 

^ 

— 

— 

\ 

^ 

1 

— 

— 

PULSE 

120 

120 

140 

80 

80 

80 

DATE 

22 

23 

24 

25 

26 

27 

28 

PUERPERAL  SEPTICAEMIA. 


61 IJ 


with  flatus,  so  that  intense  tympanites  often  form  a  most  distressing 
symptom.  The  countenanee  is  salloAV,  sunken,  and  has  a  very  anxious 
expression.  As  a  rule,  intelligenee  is  unimpaired,  and  this  may  be  tlie 
case  even  in  the  worst  forjus  of  the  disease  and  up  to  the  period  of 
death.  At  other  times  there  is  a  good  deal  of  low  muttering  delirium, 
which  often  occurs  at  night  alone,  and  alternates  with  intervals  of  com- 
plete consciousness,  but  is  occasionally  intensified  for  a  sliort  time  into 
a  more  acute  form.  Diarrhoea  and  vomiting  are  of  very  frequent  occur- 
rence; by  the  latter  dark,  gnimous,  coffee-ground  substances  are  ejected. 
The  diarrhoea  is  occasionally  veij  profuse  and  uncontrollable ;  in  mild 


Mrs.  N- 


FiG.  202. 

age  22 ;  confined  Thursdaj-,  May  6, 1880.    Forceps.    Lochia  from  tlie  first  ofi"ensive  ; 
a  small  piece  of  membrane  was  probably  left  in  tdcro. 


TIME 

M|E 

mIe 

M|E 

M 

E 

M 

E 

M 

E 

M|E 

m|e 

M 

E 

M 

E 

m{e 

m|e 

M  E 

m|e 

I 

1 

1 

1.1 

l; 

, 





1^- 





! 









'? 

! 





1 

107 

100 
ios° 
joS 
103 

X     102 

X              o 

<     lOO 

o: 

s           , 
"     99 

NORM.TEM 
OF  BODY 

q8 

— 

~ 

~ 

~ 

~ 

~ 

LZ- 

~ 

CL- 

~ 

~ 

n 

Z-  — 

1 

~ 

~ 

— 

— 

^^ 

Flft 

— 

— 

— 

K~" 



— 



1 

, 

<o 

1 

1 , 



Q_y. 

.<D_£. 

' 

(3  J 

or._ 

— 

' 

— 

I--0- 

— . — 

cc^l 

m  — 



h 

S 

.o. 

l^. 

c_ 

^xz 

;- 

k- 

1 







__i 



— 



-or 

-zi- 

1 J 

' — 

— 

«- 

1 — 

^- 

— 

-^ 

— 

1 

T 

s- 

L 

1 

-r^lo: 

1 

OT 

o 

i'i 

1 

o 

1 

~ 

~ 

I 

1 

1 

1 

nl 

r 

1 

1 

1 

1 

1 

1 

1 

1 

/^ 

f 

\\ 







„ 



4 

- 

^f- 

_ 



1 

-^.1 





1 



— 



1 — 

1 

— 

— 

-^ 

F 

yV 

— 

1 — 

— 

- 

-[-*H 

~Ar 



— — 

\ 

1/ 

i 

1 

/-\ 

— 

— 

— 

— 

\h 

/ 

1 

\ 

\   A 

1 

1 

1 

'  \ 

V 

H 

— 

t 

1 

1 

A 

— 

\    / 

V 

■^ 

V 

1 

1 

1 

1 

PULSE 

84 

96 

84 

116 

96 

120 

83 

73 

DATE 

6 

7 

8 

9 

10 

n 

12 

13 

14 

15 

16 

17 

18 

19 

cases  it  seems  to  relieve  the  severity  of  the  symptoms.  The_tougue  is 
moist  and  loaded  with  sordes,  but  sometimes  it  gets  dark  and  drv,  espe- 
cially toward  the  termination  of  the  disease.  The  lochia  are  generally 
suppressed  or  altered  in  character,  And  sometimes  they  have  a  highly 
offensive  odor,  especially  when  the  disease  is  autogenetic.  The  breath- 
ing  is  hurried  and  panting,  and  the  breath  itself  has  a  very  character- 
istic, heavy,  sweetish  odor.  The  secretion  of  milk  is  often,  but  not 
always,  arrested. 

Duration. — With  more  or  less  of  these  symptoms  the  case  goes  on, 
and  when  it  ends  fatally  it  generally  does  so  \vitliin  a  ^veek,  the  fatal 
termination  being  indicated  "by   more  weaknesT,'Tir[)icI7Tri read-like,  or 


620 


THE  PUERPERAL  STATE. 


iutermitteut  pulse,  marked  delirium,  great  tympanites,  and  sometimes  a 
sudden  fall  of  temperature,  until  at  last  the  patient  sinks  with  all  the 
symptoms  of  profound  exhaustion. 

In  milder  cases  similar  symptoms,  variously  modified  and  combined, 
are  present.  It  is  seldom  that  two  precisely  similar  cases  are  met  M'ith: 
in  some  the  rapid,  w^eak  pulse  is  most  marked ;  in  others,  abdominal 
distension,  vomiting,  diarrhoea,  or  delirium. 

Local  complications  variously  modify  the  symptoms  and  course  of 
the  disease.  The  most  common  is  peritonitis,  so  much  so  that  with 
some  authors  puerperal  fever  and  puei'peraTjDeritonitis  are  synonymous 
terms.  Here  the  first  symptom  is  severe  abdominal  pain,  commencing 
at  the  lower  part  of  the  abdomen,  where  the  uterus  is  felt  enlarged  and 


Mrs. 


Fig.  203. 

,  age  25  ;  recovery.     Confined  July  26,  1S79,  7.40  P.  M. 


TIME 

M    E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M    E 

m!e 

M 

E 

M    E 

MJE 

M 

E 

M 

e 

7 

E 

M 

E. 

M 

E 

M 

E 

7 

R 

BOWELS 

1 

1 

1 

1 

2 

1 

1 

2 

1 

1 

3 

1 

3 

1 

1 

1 

2 

2 

1 

' 

107" 
lob 

104 

'P 

1    103 

I 

£       o 

—     lOI 

g    100 

a. 

£ 

^    99° 

— |— 

— 

.-^ 

-rf 

1 

1 

r~ 

1 

a-5— 

1 

1 

1 

' 

1 



1 

j 

^— 



1 

_ 

- 

— ^-1 

H-^ 

{ 

: 

' 

— 

1 

— 

— 

1 

~ 

~<! 

n- 

i 

;— 

j 

1 

— ! — 

' — 

1 

1 

1 

j 

:,i.    1 

_ 

<V     ' 

: 

1 

A 

"1 

] 

\ 

e' 

I 

1 

[ 

1 

■ 

1 

1 

1 

1 

1 

1 

J  fi 

1 

1 

i 

n 

'!\ 

' 

1 

1 

n\ 

17 

j 

' 

1 

1 

j 

1 

/ 

1 

1 

1 

1 

! 

/ 

r\ 

t 

1 

1 

j] 

l\ 

1 

1 

1 

- 

,n 

*  1 

^ 

Pr 

_!_ 

— 

1 

/ 

1 

1 

\  f 

- 

— 

1 

\ ' 

\i 

\ 

1 

— 

)[ 

, 

\' 

1  , 

1 

1 

1 

\ 

1  n 

1 

1 

(' 

\ 

1  \ 

1 

'  / 

y 

j      \ 

1 

\ 

7 

' 

- 

- 

/-- W 

II 

j 

1 

1 

.- 

j 

■ 

j 

1 

1 

1 

; 

Y 

i\          ' 

1 

\l           ' 

1— 

1 

1 

\  1 

\ 

• 

! 

j 

\\  1 

\ 

' 

'\ 

1 

j 

1 

' 

1 

j  • 

1 

1 

1 

' 

\ ' 

' 

1 

f 

I 

' 

1 

j 

A 

-/- 

j 

__ 



1 









■ 

■ 

1 

1 

H — 

( 

LA 

-7^ 

1 

' 

NORM.TEM 

OF  Eooy 

o 

98 

— ' 

— 

4- 

] 

— 

— 

— 

— 

— 

— 

^— 

H— 

— 1 — 

^ , 

— 1 — 

—h- 

V 

Vt 

— ' — 
* 

— i — 

- 

' 

, 

- 

j 

* 

! 

1 

1 

1 

j 

1 

1 

1 

1 

! 

-- 

1 

' 

; 

f 

1 

1 

■ 

; 

1 

j 

j 

i 

1 

1 

1 

' 

, 

1 

1 

, 

1 

1 

1 

1 

1 

1 

1 

1 

DAY  OF 
DIS. 

1ST. 

2ND. 

3RD. 

4TH, 

5TH. 

5TH. 

7TH. 

8TH. 

9TH. 

10TH 

11TH 

12th. 

13TH 

UTH 

15TH 

16th 

17TH 

PULEE 

Xis 

94^^ 

i^° 

^;2\ 

."JS\ 

;^ 

"^ 

^J^ 

r.-^^ 

^' 

;^ 

r^i^^ 

'J>^ 

^ 

^ 

^ 

^ 

\90 

\90 

^ 

^ 

DATE 

26 

21 

28 

29 

30 

31 

Aug1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

tender.  As  the  abdominal  pain  and  tenderness  spread,  the  suiFerings  of 
the  patient  greatly  increase,  the  intestines  become  enormously  distended 
with  flatus,  and  the  breathing  is  entirely  thoracic,  in  consequence  of  the 
upward  displacement  of  the  diaphragm  and  the  fact  that  the  abdominal 
muscles  are  instinctively  kept  as  much  in  repose  as  possible.  The 
patient  lies  on  her  back,  with  her  knees  drawn  up,  and  sometimes  can- 
not bear  the  slightest  pressure  of  the  bed-clothes.  There  is  generally 
much  vomiting,  and  often  severe  diarrhoea.  The  temperature  generally 
ranges  from  102°  to  104°,  or  even  106°,  and  is  subject  to  occasional 
exacerbations  and  remissions,  possibly  depending  on  fresh  absorption  of 


P  UERPERA  L  SEPTICEMIA . 


621 


septic  matter.  (See  Figs.  200,  203,  and  202.)  The  case  generally  lasts 
for  a  week  or  more,  the  syrajjtoms  going  on  from  bad  to  worse  and  the 
patient  dying  exhausted.  D'Espine  points  out  that  rigors,  with  exacer- 
bations of  the  general  symptoms,  not  unfrequently  occur  about  the 
sixth  or  seventh  day,  which  he  attributes  to  fresh  systemic  infection 
from  fetid  pus  in  the  peritoneal  cavity.  It  must  not  be  supposed  that 
all  these  symptoms  are  necessarily  present  when  the  peritonitic  complica- 
tion exists.  _  Painis  especially  often  entirely  absent,  and  I  have  seen 
cases^  in  which'post-mortem  "exam^iiiation  proved  the  existence  of  peri- 
touitis^  in  a  very  marked  degree,  in  which  pain  was  entirely  absent.' 
Sometimes  the  pain  is  only  slight,  and  amounts  to  little  more  than  ten- 
derness over  the  uterus. 

Fig.  204. 
Mrs.  M.  K ,  age  21 ;  infection  believed  to  be  due  to  scarlatina.    Confined  .\ng.  5, 1878  ;  recovery: 


TIME 

M 

E 

M 

E 

M 

B 

M 

E 

i 

E 

M 

E 

M 

E 

M 

E 

M   E 

m|e 

M 

E 

M 

E 

r— ) — 
M|E 

M 

E 

M  E 

m|e 

mIe 

mIe 

ME 

mIe 

1 

1 

1 

107 

job 
105 
104 

"p 

"     102 

-z. 

1  ^ 

2  loi 

m 

i  ^°° 

H     99 

KORM.TEM 
OF  BODY 

1 

1 

1 

1 

1 

1 

[ 

: 

1 

\  ■ 

1 

1 

- 

-^ 

-+- 

= 

— 

o— 

1 

w 

zn 

— 

— 

J 

^rz 

^ 

' 

z 



^ 

^ 

— TTT 

z 

_ 

t 

1  _J 

'Z^'-(^ 

~ 

1 

o^ — 

1 

L^- 

— 

— 

~ 

_ 

o 

'z 

'Z 

ii< 

^z. 

q:-' — 

1  <" 

JSj\_< 

1 

-Q-j — 

— 

1 

— — 

= 

i- 

— 

_ 

= 

~ 

.5 

-O 

i 

~ 

H 

.c 

■'if-' 

— '-S- 

— \t 

-Q^UJ 

^ 

— 

— 

~i 

.g 

— ^ 



1 

LJL 

— ^UJ^ 



1 , 

^\ 

' 

1 1 

— 

\^ 

— 

' — 

— ' 

' ' 

n 

<>- 

— r^" 

-Dl-2 

1 

orr~ 

— 1 — 





\ 

- 

\~ 

-CE- 

^j^; 

9 1 

1 

1 

pr^ 

-y— 

c\ 

■01 

, 

L 

_ 

1 

, 

_ 

- 



^ 

1 

_jZI 

1 

.O- 

, 

~ 

— 

— 

— ' 

^^ 

-r" 

/j 

— 1 — 

CC           ; 

-u.- 

l\ 

1 

1 

■ 

/ 

f  1 

A 

1 

/ 

1 

^ 

I 

_) 

/  \ 

4^ 

< 

'I 

^  1 

V, 

%^ 

1 

/  \ 

1 

1 

V) 

1 

1 

\\ 

j  \ 

/ 

i 

\ 

_| 

1 

\  ^ 

\ 

I 

1 

/[ 

1 

1 

\  /' 

1 

•n 

1 

\ 

/ 

1 

\ 

1 

V 

1 

1 

1 

1 

1 

1 

i 

1 

1 

1 

1 

I 

1 

1 

1 

\^ 

^ 

1 

• 

1 

1 

1 

1 

1 

1 

1 

1 

1 

' 

DAY  OF 
DIS. 

1ST. 

2nd. 

3RD. 

4th. 

6TH. 

6th. 

/TH. 

8TH. 

9TH. 

10TH. 

11th 

12th. 

ISth! 

14th. 

15TH 

16TM 

17TH 

1STH. 

I9TH 

20TH. 

PULSE 

130 

120 

150 

-.0  0 

DATE 

Aug6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

Symptoms  of  other  local  complications  are  characterized  by  their  own 
special  symptoms :  thus,  pneumonia  by  dyspnoea,  cough,  dulness,  etc. ; 
pericarditis  by  the  characteristic  rub ;  pleurisy  by  dulness  on  percussion ; 
kidney  affection  by  albuminuria  and  the  presence  of  casts ;  liver  compli- 
cation by  jaimdice ;  and  so  on. 

Pysemic  Forms  of  the  Disease. — The  course  of  the  di.sease  is  not 
always  so  intense  and  rapid,  being  in  some  cases  oTa  nlore  chronTc'c'lia- 
racter  and  lasting  many  weeks.  The  symptoms  in  the  early  stage  are 
oiten  indistin^uTsEable  from  those  already  described,  and  it  is  generally 
only  after  the  second  week  that  indications  of  purulent  infection  develop 
themselves.  Then  we  often  have  recurrent  and  very  severe  rigors,  with 
marked  elevations  and  remissions  oOemj^erature.     At  the  same  time, 


622  THE  PUERPERAL  STATE. 

there  is  generally  an  exacerbation  ctf  the  general  symptoms,  a  })eciiliar 
yellowish  discoloration  of  the  skin,  and  occasionally  Avell-develo])ed 
jaundice.  Transient  patches  of  erythema  are  not  uncommonly 
observed  on  various  parts  of  the  skin,  and  such  eruptions  have  often 
been  mistaken  for  those  of  scarlet  fever  or  other  zymotic  disease. 
Localized  inflammations  and  suppuration  may  rapidly  follow. 
Amongst  the  most  common  are  inflammation,  or  even  suppuration, 
of  the  joints — the  knees,  shoulders,  or  hips — which  is  preceded  by 
difficulty  of  movement,  swelling,  and  very  acute  pain.  Large  collec- 
tions of  pus  Jn  various  parts  of  the  muscles  and  connective  tissue  are 
not  rare.  "SujDpurative  inflammation  may  also  be  found  in  connection 
with  many  organs,  as  in  the  eye,  in  the  pleura,  pericardium,  or  -lungs ; 
each  of  Avhich  will  of  course  give  rise  to  characteristic  symjDtoms,  more 
or  less  modified  by  the  type  of  the  disease  and  the  intensity  of  the 
inflammation. 

Puerperal  Malarial  Fever. — There  is  a  peculiar  form  of  febrile 
disturbance  which  sometimes  occurs  in  the  puerperal  state,  and  which 
is  apt  to  be  confounded  with  septicaemia,  to  which  attention  has  recently 
been  specially  directed  by  Fordyce  Barker^  under  the  name  of ''puer- 
peral malarial  fever."  =  It  is  specially  apt  to  be  met  with  in  Momen 
who  have  been  exposecLto  malaria]  poison  during  their  former  lives, 
the  recurrence  of  tlie  fever  being  probably  determined  by  the  puer- 
peral state.  Of  this  I  have  seen  several  very  well-marked  examples 
in  ladies  who  have  formerly  contracted  fever  and  ague  in  India.,/  One 
of  my  patients,  who  has  long  been  in  India  and  suffered  from  inter- 
mittent fever  for  years,  is  invariably  attacked  with  it  after  delivery, 
and  herself  warnecl  me  of  the  fact  the  first  time  I  attended  her.  The 
diagnosis  is  not  always  easy.  Barker  insists  on  the  fact  that  puerperal 
malarial  fever  generally  commences  after  the  fifth  day  from  delivery, 
while  septicaemia  almost  always  does  so  before  that  time.  In  the 
malarial  fever,  moreover,  the  intermissions  are  much  more  marked, 
while  there  are  frequently  recurring  chills  or  rigors;  which  is  not 
the  case  in  septicasmia. 

Treatment. — In  considering  the  all-important  subject  of  treatment 
the  views  of  the  practitioner  are  naturally  biassed  by  the  theory  he  has 
adopted  of  the  nature  of  the  disease.  If  that  here  inculcated  be  correct, 
the  indications  we  have  to  bear  in  mind  are — 1st,  to  discover,  if  possible, 
the  source  of  the  poison,  in  the  hope  of  arresting  further  septic  absorp- 
tion ;  2dly,  to  keep  the  patient  alive  until  the  effects  of  the  poison  are 
worn  off;    and  3dly,  to  treat  any  local  complication  that  may  arise. 

The  first  is  likely  to  be  of  great  importance  in  cases  of  self-infection, 
as  fresh  quantities  of  septic  matter  may  be  from  time  to  time  absorbed. 
AVe,  fortunately,  are  in  possession  of  a  powerful  means  of  preventing 
further  absorption  by  the  application  of  antiseptics  to  the  interior  of  the 
uterus  and  to  the  canal  of  the  vagina.  This  is  especially  valuable 
when  the  existence  of  decomposing  coagula  or  other  sources  of  septic 
matter  is  sus^^ected  in  the  uterine  cavity  or  when  offensive  discharges 
are  present.  Disinfection  is  readily  accomplished  by  washing  out  the 
uterine  cavity  at  least  twice  daily  by  means  of  a  Higginsou   syringe 

1  "Puerpei-al  Malarial  Fever,"  Amer.  Journ.  of  Obstet.,  1880,  vol.  xiii.  p.  271. 


PUERPERAL  SEPTICMMIA. 


62; 


with  a  long  vaginal  pipe  attached.^     The  results  are  sometimes  very 
remarkable,  the  threatening  symptoms  rapidly  disappearing,  and  the 

Fig.  205. 
Mrs.  B ,  age  29;  confined  March  29;  died  April  7,  1879. 


TIME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

1 1 

MIE 

M 

E 

M 

E 

'iob° 
las' 
J04 

I 

I    102° 

< 

i   100 
99° 

NORM.TEM 
OF  BODY 

■■ 

E 

= 

E 

i 

~ 

~ 

E 

~ 

~ 

— 

E 

E 

— 

— 

— 

~ 

— 

z 

d 

— 

E 

— 

^ 

ZZ 

~ 

— 

— 

— 

- 

— 

— 

— 

— 

— 

— 

— 

— 

/ 

— 

— 



— 1 

R 

4- 

- 

pi 

rj»- 

■««- 

_ 

- 

-r-\ 

/ 

— 

\- 

P 

^ 

— 







4- 

LJ_ 

1 

l 

V 

■ 

\- 

— 

— 

Y~ 

1 

1- 

— 

'~\ 

^ 

— 

F 

A 

1 — 



> — 

— 

\ 

V, 





- 

— 

^ 

~ 

~ 

~ 

_ 

— 

— 

— 

— 

— 

— 

— 

—^ 

- 

- 

— ' 



— 

— 

— 



P 

' 

1 

1 

— 

\f 

1 

DAY  OF 
DIS  , 

1ST. 

2n0. 

3rd. 

4TH. 

5TH. 

6th. 

7TH. 

STH. 

9th. 

PULSE 

\ 

,>^ 

\100 

\126 

\136 

\ 

\ 

\ 

t^ 

DATE 

IVlr29 

30 

3t 

Apr.l 

z 

3 

4 

5 

6 

7 

temperature  and  pulse  falling  so  soon  after  the  use  of  the  antiseptic 
injections  as  to  leave  no  doubt  of  the  beneficial  effects  of  the  treatment. 
I  cannot  better  illustrate  the  advantages  of  this  treatment  than  by  the 
temperature  chart  (Fig.  207),  which  is  from  a  case  which  came  under 
my  observation  in  the  outdoor  practice  of  King's  College  Hospital. 
It  was  that  of  a  healthy  woman,  thirty-six  years  of  age,  who  had  an 
easy  and  natural  labor.  jSTotliing  remarkable  was  observed  until  tlie 
third  day  after  delivery,  when  the  temperature  was  found  to  be  slightly 
increased.     On  the  morning  of  the  eighth  day  the  temperature  had 

^  My  colleague,  Dr.  Hayes,  has  invented  a  silver  tube  for  the  purpose  of  administer- 
ing such  intra-uterine  injections  (Fig.  206),  which  answers  its  purpose  admirably.   The 

Fig.  206. 


Hayes'  Tube  for  Intra-uterine  Injections. 
numerous  apertures  at  its  extremity  allow  of  a  number  of  minute  streams  of  fluid  being 
thrown  out  in  the  form  of  a  spray  over  the  interior  of  the  uterus,  the  complete  bathing  of 
its  surface  and  washing  out  of  its  cavity  being  thus  ensured.    It  is,  moreover,  introduced 
more  easily  than  the  ordinary  vaginal  pipe,  and  can  be  attached  to  a  Higginson  syringe. 


624 


THE  PUERPERAL  STATE. 


risen  to  105.8°.  She  was  delirious,  with  a  rapid  thready  pulse,  clammy 
perspiration,  tympanitic  abdomen,  and  her  general  condition  indicated 
the  most  urgent  danger.  On  vaginal  examination  a  piece  of  com- 
pressed and  putrid  placenta  was  found  in  the  os.  This  was  removed 
by  my  colleague,  Dr.  Hayes,  and  the  uterus  thoroughly  washed  out 
with  Condy's  fluid  and  water.  The  same  evening  the  temperature  had 
sunk  to  99°  and  the  general  symptoms  w^ere  much  improved.  The 
next  day  there  was  a  slight  return  of  offensive  discharge  and  an  aggra- 
vation of  the  symptoms.  After  again  washing  out  the  uterus  the  tem- 
perature fell,  and  from  that  date  the  patient  convalesced  without  a 
single  bad  symptom.     (See  also  Fig.  201.) 

This  is  a  very  well-marked  example  of  the  value  of  local  antiseptic 
treatment,  and  I  have  seen  many  cases  of  the  same  kindT"  "It  sliould 
therefore  never  be  omitted  in  all  cases  in  which  self-infection  is  possible ; 
and,  indeed,  even  when  there  is  no  reason  to  suspect  the  presence  of  a 
local  focus  of  infection  the  use  of  antiseptic  lotions  is  advisable  as  a 

matter  of  j)recaution,  since  it  can  do  no 
Fig.  207.  harm  and  is  generally  comforting  to  the 

patient.  Various  antiseptics  may  be 
used,  such  as  a  weak  solution  of  carbolic 
acid,  1  in  50,  tincture  of  iodine  dropped 
into  warm  water  until  it  has  a  pale  sherry 
color,  Condy's  fluid  largely  diluted,  or  a 
solution  of  perchloride  of  mercury  of 
the  strength  of  lju_^Q00.  Of  these, 
the  perchloride-of-mercury  solution  is 
the  most  eifective  germicide,  and  Koch's 
experiments  have  conclusively  proved 
that  it  is  the  only  recognized  antiseptic 
which  can  be  relied  upon  for  destroying 
the  spores  of  micro-organisms  after  a  single  application.  [Solution  of 
the  biniodide  of  mercury,  1  part  to  4000,  has  been  fully  tested  as  a  ger- 
micide in  this  country,  Russia,  France,  and  Italy,  and  has  been  pro- 
nounced a  less  poisonous  and  more  pow-erful  antiseptic  than  corrosive 
sublimate  by  several  careful  observers :  it  is  also  less  irritating.  By 
the  addition  of  iodide  of  potassium  it  is  made  readily  soluble.  (See 
paper  by  Dr.  Eugene  P.  Bernarcly  of  Philadelphia  in  Trans.  County 
Med.  Soc.  Fhila.,  for  Jan.  23,  1889.)— Ed.]  As,  how^ever,  there  is  a 
possibility  that  a  too  free  and  incautious  use  of  the  corrosive  sublimate 
might  prove  poisonous,  it  would  be  well  that  such  intra-uterine  injec- 
tions should  not  be  stronger  than  1  in  2000,  and  that  they  should  be 
practised  by  the  medical  man  himself,  the  quantity  for  such  irrigation 
not  exceeding  two  quarts.^  One  or  other  of  these  may  be  advantage- 
ously used  alternately — one  in  the  morning,  the  other  in  the  evening. 
Occasionally  I  have  employed  a  l-in-50  solution  of  carbolic  acid,  with 
about  5  grs.  to  the  ounce  of  iodoform  suspended  in  it.  This  has  the 
advantage  of  not  only  being  a  powerful  antiseptic,  but  of  acting  more 
continuously,  in  consequence   of   the   powdered   iodoform    remaining 


1  Herff, 
Gyniik.,  li 


IJeber  Ursachen  und  Verhiitung  der  Sublimat-Vergiftung,  etc., 
35,  Bd.  XXV.  S.  487. 


Arch.  f. 


PUERPERAL  SEPTICEMIA.  625 

partially  attached  to  the  uterine  walls ;  or,  as  some  have  advised,  an 
iodoform  bougie  ^  may  be  placed  in  the  uterine  cavity  or  powdered 
iodoform  insufflated  through  the  cervix.  The  nozzle  of  the  syringe 
should  be  guided  well  through  the  cervix,  and  the  cavity  of  the  uterus 
thoroughly  washed  out  until  the  fluid  that  issues  from  the  vagina  is  no 
longer  discolored.  As  the  os  is  always  patulous,  there  is  no  risk  of 
producing  the  troublesome  symptoms  of  uterine  colic  which  occasion- 
ally follow  the  use  of  intra-uterine  injections  in  the  unimpregnated 
state.  It  is  quite  useless  to  entrust  the  injection  to  the  nurse,  and  it 
should  be  performed  at  least  twice  daily  by  the  practitioner  himself 
in  all  cases  in  which  the  discharges  are  oflFeusive.  It  is  not  advisable, 
however,  that  such  injections  should  be  used  indiscriminately,  since 
they  are  not  entirely  free  from  risk,  nor  should  they  be  continued  for 
more  than  a  few  days.  It  has  been  pointed  out  ^  that  sometimes  the 
intra-uterine  injection  itself  produces  rigors  and  other  nervous  troubles. 
I  am  certain  that  this  observation  is  correct,  and  I  have  myself  more 
than  once  seen  a  severe  rigor  rapidly  follow  its  administration.  The 
vulva  should  in  all  cases  be  carefully  inspected,  with  the  view  of  ascer- 
taining if  the  source  of  infection  be  not  some  local  slough  or  necrotic 
ulcer  about  the  perineum  or  orifice  of  the  vagina,  in  which  case  its 
surface  should  be  freely  covered  with  iodoform.  I  have  seen  more 
than  one  instance  in  which  this  simple  procedure  has  sufficed  to  cut 
short  symptoms  of  a  very  threatening  character. 

In  a  disease  characterized  by  so  marked  a  tendency  to  prostration  the 
importance  of  sustaining  the  vital  powers  by  an  abundance  of  easily 
assimilated  nourishment  cannot  be  overrated.  Strong  beef-tea  or  other 
forms  of  animal  soup,  milk  alone  or  mixed  either  w1th'~Iime~'or  soda- 
water,  and  the  yolk  of  eggs  beat  up  with  milk  and  brandy,  should  be 
given  at  short  intervals  and  in  as  large  quantities  as  the  patient  can  be 
induced  to  take ;  and  the  value  of  thoroughly  efficient  nursing  will  be 
especially  apparent  in  the  management  of  this  important  part  of  the 
treatment.  As  there  is  frequently  a  tendency  to  nausea,  the  patient  may 
resist  the  administration  of  food,  and  the  resources  of  the  practitioner 
will  be  taxed  in  administering  it  in  such  form  and  variety  as  will  prove 
least  distasteful.  Generally  speaking,  not  more  than  one  or  two  hours 
should  be  allowed  to  elapse  without  some  nutriment  being  given.  The 
amount  of  stimulant  required  will  vary  with  the  intensity  of  the  symp- 
toms and  the  indications  of  debility.  Generally,  stimulants  are  well 
borne,  prove  decidedly  beneficial,  and  require  to  be  given  pretty  freely. 
In  cases  of  moderate  severity  a  tablespoonful  of  good  old  brandy  or 
whiskey  every  four  hours  may  suffice;  but  when  the  pulse  is  very  rapid 
and  thready,  when  there  is  much  low  delirium,  tympanites,  or  sweat- 
ing (indicating  profound  exhaustion),  it  may  be  advisable  to  give  them 
in  much  larger  quantities  and  at  shorter  intervals.  The  careful  prac- 
titioner will  closely  watch  the  effects  produced,  and  regulate  the  amount 
by  the  state  of  the  patient  rather  than  by  any  fixed  rule;  but  in  severe 

1  These  may  be  made  of  gum  arable  and  glycerin,  about  2^  inches  in  length,  each 
containing  90  grains  of  iodoform. 

2  Mangin,  "  Quelques  accidents  provoqufe  par  les  injections  intra-ut«rines,"  Nowv. 
Arch.  d'Obstet.  et  de  Gyn.,  1888,  p.  38. 

40 


626  THE  PUERPERAL  STATE. 

cases  eight  or  twelve  ounces  of  braudy,  or  even  more,  in  the  twenty- 
four  hours  may   be  given  with  decided  benefit. 

Venesection,  both  general  and  local,  was  long  considered  a  sheet- 
anchor  in  this  disease.  Modern  view^s  are,  however,  entirely  opposed  to 
its  use;  and  in  a  disease  characterized  by  so  profound  an  alteration  of 
the  blood  and  so  much  prostration  it  is  too  dangerous  a  remedy  to 
employ,  although  it  is  possible  that  it  might  alleviate  temporarily  the 
severity  of  some  of  the  symptoms,  especially  in  cases  in  which  peritoni- 
tis is  well  marked  and  much  local  pain  and  tenderness  are  present. 

The  rational  indications  in  medicinal  treatment  are  to  lessen  the  force 
of  the  circulation  as  much  as  is  possible  wdthout  favoring  exhaustion 
and  to  diminish  the  temperature. 

For  the  former  purpose  Barker  strongly  advocates  the  use  of  the 
tincture  of  veratrum  viride,  in  doses  of  five  drops  every  hour,  until  the 
pulse  falls  to  below  100,  wdien  its  eifects  are  subsequently  kept  up  by 
two  or  three  drops  every  second  hour.  Of  this  drug  I  have  no  per- 
sonal experience,  but  I  have  extensively  used  minute  doses  of  tincture 
of  aconite  for  the  same  purpose,  and  when  carefully  given  I  believe  it 
to  be  a'most  valuable  remedy.  The  way  I  have  administered  it  is  to 
give  a  single  drop  of  the  tincture,  at  first  every  half  hour,  increasing 
the  interval  of  administration  according  to  the  effect  produced.  Gener- 
ally, after  giving  four  or  five  doses  at  intervals  of  half  an  hour,  the 
pulse  begins  to  fall,  and  afterw^ard  a  few  doses  at  intervals  of  one  or  two 
hours  will  suffice  to  prevent  the  heart's  action  rising  to  its  former  rapid- 
ity. The  advantage  of  thus  modifying  cardiac  action  wdth  the  view  of 
preventing  excessive  waste  of  tissue  cannot  be  questioned.  It  is  evi- 
dent that  so  powerful  a  remedy  must  not  be  used  without  the  most 
careful  supervision,  for  if  continued  too  long  or  given  at  too  frequent 
intervals  it  may  unduly  depress  the  circulation  and  do  more  harm  than 
good.  It  is  necessary,  therefore,  that  the  practitioner  should  constantly 
watch  the  effect  of  the  drug,  and  stop  it  if  the  pulse  become  very  weak 
or  if  it  intermit.  It  is  most  likely  to  be  useful  at  an  early  stage  of  the 
disease  before  much  exhaustion  is  present,  and  then  only  when  the 
pulse  is  of  a  certain  force  and  volume.  Barker  says  of  the  veratrum 
viride,  what  is  also  true  of  aconite,  that  "it  should  not  be  given  in 
those  cases  in  which  rapid  prostration  is  manifested  by  a  feeble,  thread- 
like,  irregular  pulse,  profuse  sweats,  and  cold  extremities." 

The  reduction  of  temperature  must  form  an  important  part  of  our 
treatment,  and  for  this  purpose  many  agents  are  at  our  disposal. 

Quinine  in  large  doses,  of  from  10  to  30  grains,  has  been  much  used 
for  tliis^purpose,  especially  in  Germany.  After  its  exhibition  the  tem- 
perature frequently  falls  one  or  two  degrees.  It  may  be  given  morning 
and  evening.  Unpleasant  head-symptoms,  deafness  and  ringing  in  the 
ears,  often  render  its  continuance  for  a  length  of  time  impossible.  These 
may,  however,  be  much  lessened  by  the  addition  of  10  to  15  minims  of 
hydrobromic  acid  to  each  dose. 

Antipyrine  in  doses  of  20  grains  every  three  or  four  hours  sometimes 
proves  very  efficacious,  but  as  it  is  ajjt  to  depress  it  should  be  combined 
with  some  stimulant,  such  as  30  minims  of  sal-volatile. 

Salicylic  acid,  in  doses  of  from  10  to  20  grains,  or  the  salicylate  of 


PUERPERAL  SEPTICEMIA.  627 

socla  in  the  same  doses,  is  a  valuable  antipyretic  which  I  have  found  on 
the  whole  more  manageable  than  quinine.  Under  its  use  the  tempera- 
ture often  falls  considerably  in  a  short  space  of  time.  It  is,  however, 
apt  to  depress  the  circulation,  and  thus  requires  to  be  carefully  watched 
while  it  is  being  administered,  and  should  the  pulse  become  very  small 
and  feeble  it  should  be  discontinued. 

In  some  cases,  especially  when  the  fever  has  assumed  a  remittent 
type,  I  administer  with  marked  benefit  a  drug  which  is  of  high  repute 
in  India  in  the  worst  class  of  malarious  remittent  fevers,  and  the  almost 
marvellous  effects  of  which  in  such  cases  I  had  myself  witnessed  in 
India  many  years  ago.  This  is  the  so-called  Warburg's  tincture,  the 
value  of  which  has  been  testified  to  by  many  high  authorities,  among 
whom  I  may  mention  Dr.  Maclean  of  Netley,  Dr.  Broadbent,  and  Sir 
Alexander  Armstrong,  the  director-general  of  the  medical  department 
of  the  navy,  who  informs  me  that  it  is  now  supplied  to  all  Her  Majesty's 
ships  in  the  tropics,  because  it  is  found  to  be  of  the  utmost  value  in 
cases  in  which  quinine  has  little  or  no  effect.  Recently  its  composition 
has  been  made  public  by  Dr.  Maclean.  The  basis  is  quinine,  in  com- 
bination with  various  aromatics  and  bitters,  some  of  which  probably 
intensify  its  action.  Be  this  as  it  may,  the  testimony  in  favor  of  the 
anti2:)yretic  action  of  the  remedy  is  very  strong.  I  have  found  its  exhi- 
bition followed  by  a  profuse  diaphoresis  (this  being  its  almost  invaria- 
ble effect),  and  sometimes  a  rapid  amelioration  of  the  symptoms.  In 
other  cases  in  which  I  have  tried  it,  like  everything  else,  it  has  proved 
of  no  avail.  Of  its  use  in  ten  malarial  cases  above  alluded  to  Dr. 
Fordyce  Barker  says :  "For  nearly  two  years  past,  in  those  cases  Avhere 
the  stomach  will  tolerate  it,  I  have  found  Warburg's  tincture  much 
more  effective  and  speedy  in  producing  the  results  desired  than  the 
largest  doses  of  quinine."^ 

Col^  may  be  advantageously  tried  in  suitable  cases.  The  simplest 
mo^eof  using  it  is  by  Thornton's  ice-cap,  by  which  a  current  of  cold 
water  is  kept  continuously  running  round  the  head.  This  has  been 
found  of  great  value  in  pyrexia  after  ovariotomy,  and  I  have  also 
found  it  useful  as  a  means  of  reducing  temperature  in  puerperal  cases. 
It  is  a  comforting  application,  and  gives  great  relief  to  the  throbbing 
headache,  which  often  causes  much  suffering.  Under  its  use  the  tem- 
perature often  falls  two  or  more  degrees,  and  it  is  easily  continued  day 
and  night. 

In  very  serious  cases,  when  the  temperature  reaches  105°  and  upward, 
the  external  application  of  cold  to  the  rest  of  the  body  may  be  tried. 
I  have  elsewhere  relatecP  a  case  of  puerperal  septicaemia  with  hyper- 
pyrexia, the  temperature  continuously  ranging  over  105°,  in  which  I 
kept  the  patient  for  eleven  days  nearly  constantly  covered  with  cloths 
soaked  in  iced  water,  by  which  means  only  was  the  temperature  kept 
within  moderate  bounds  and  life  preserved.  But  this  method  of  treat- 
ment is  excessively  troublesome,  and  is  in  no  way  curative.  It  is  only 
of  use  in  moderating  the  temperature  when  it  has  reached  a  point  at 

1  Op.  eit.,  p.  278. 

^ "  A  Lecture  on  a  Case  of  Puerperal  Septicaemia,  with  Hyperpyrexia,  treated  by 
the  Continuous  Application  of  Cold,"  Brit.  3Ied.Jouni.,  1877,  vol.  ii.  p.  687. 


628  THE  PUERPERAL  STATE. 

Avhich  it  could  not  coutinue  loug  without  destroying  the  patient.  I 
should  therefore  never  think  of  employing  it  unless  the  temperature 
was  over  105°,  and  then  only  as  a  temporary  expedient,  requiring  inces- 
sant watching,  and  to  be  desisted  from  as  soon  as  the  temperature  has 
reached  a  niore  moderate  height.  It  is  clearly  impossible  to  place  a 
puerperal  patient  in  a  bath,  as  is  practised  in  hyperpyrexia  associated 
with  acute  rheumatism  or  typhoid  fever.  The  same  effect  may,  how- 
ever, be  obtained  by  placing  her  on  macintosh  sheeting,  or,  still  better, 
on  a  water-bed,  into  which  cold  water  is  run  from  time  to  time,  and 
covering  the  body  M'ith  towels  soaked  in  iced  water,  which  are  frequently 
renewed  by  the  attendant  nurses.  During  the  application  the  temper- 
ature should  be  constantly  taken,  and  as  soon  as  it  has  fallen  to  101° 
the  cold  applications  should  be  discontinued. 

Amongst  other  remedies  which  have  been  used  is  turpentine,  which 
was  highly  thought  of  by  the  Dublin  school.  In  cases  with  much  tym- 
panitic distension  and  a  small  weak  pulse  it  is  sometimes  of  unquestion- 
able value,  and  it  probably  acts  as  a  strong  nervine  stimulant.  Given 
in  doses  of  15  to  20  minims  rubbed  up  with  mucilage,  it  can  generally 
be  taken  in  spite  of  its  nauseous  taste. 

Purgatives,  diaphoretics,  or  even  emetics,  have  often  been  employed 
as  eliminants  of  the  poison.  The  former  are  strongly  recommended  by 
Schroeder  and  other  German  authorities,  and  in  England  they  were 
formerly  amongst  the  most  favorite  remedies,  and  there  is  a  general  con- 
currence of  opinion  amongst  our  older  writers  as  to  their  value.  In 
the  first  volume  of  the  Obstetrical  Journal  there  is  a  paper  by  Mr.  Mor- 
ton in  which  this  practice  is  strongly  advocated,  and  some  interesting 
cases  are  recorded  in  which  it  apparently  acted  well.  He  administers 
calomel  in  doses  of  3  or  4  grains  with  compound  extract  of  colocynth, 
so  as  to  keep  up  a  free  action  of  the  bowels.  \  It  seems  quite  reasonable, 
when  there  is  constipation,  to  promote  a  gentle  action  of  the  bowels  by 
some  mild  aperient ;  but,  bearing  in  mind  that  severe  and  exhausting 
diarrhoea  is  a  common  accompaniment  of  the  disease,  I  should  myself 
hesitate  to  run  the  risk  of  inducing  it  artificially,  especially  as  there  is 
no  proof  w'hatever  that  septic  matter  can  really  be  eliminated  in  this 
way.  At  the  commencement  of  the  disease,  however,  I  have  often 
given  one  or  two  aperient  doses  of  calomel  with  decided  benefit. 

It  is  possible  that  further  research  will  give  us  some  means  of  coun- 
teracting the  septic  state  of  the  blood,  and  the  sulphites  and  carbolates 
have  been  given  for  this  purpose,  but  as  yet  with  no  reliable  results. 

The  tincture  of  the  perchloride  of  iron  naturally  suggests  itself,  from 
its  well-known  effects  in  surgical  pyfemia.  In  the  less  intense  forms  of 
the  disease,  especially  when  local  suppurations  exist,  it  is  certainly  use- 
ful, and  may  be  given  in  doses  of  10  to  20  minims  every  three  or  four 
hours.  In  very  acute  cases  other  remedies  are  more  reliable,  and  the 
iron  has  the  disadvantage  of  not  unfrequently  causing  nausea  or  vom- 
iting. 

When  restlessness,  irritation,  and  want  of  sleep  are  prominent  symp- 
toms sedatives  may  be  required.  Under  such  circumstances  oi)iates  may 
be  given  at  night,  and  Battley's  solution,  nepenthe,  or  the  hypodermic 
injection  of  morphia  is  the  form  which  answers  best. 


PUERPERAL    VENOUS  THROMBOSIS  AND  EMBOLISM.       629 

Pain  and  tenderness  and  local  complications  must  Ije  treated  on 
general  principles.  The  distress  from  them  is  most  experienced  when 
peritonitis  is  well  marked.  Then  warm  and  moist  applications  in 
the  form  of  poultices  or  fomentations  are  very  useful.  Relief  is 
also  sometimes  obtained  from  turpentine  stupes,  and  when  the  tym- 
panites is  distressing  turpentine  enemata  are  very  serviceable.  I  have 
found  the  free  application  over  the  abdomen  of  the  flexible  collodium 
of  the  Pharmacopoeia  decidedly  useful  in  alleviating  the  suffering  from 
peritonitis. 

Such  are  the  remedies  most  used  in  this  disease.  It  is  needless  to  say 
that  it  is  quite  impossible  to  lay  down  fixed  rules  for  the  management 
of  any  individual  case ;  and  it  is  obvious  that  if  puerperal  septiceemia 
be  not  a  special  and  distinct  disease,  its  judicious  treatment  must  depend 
on  the  general  knowledge  of  the  attendant  and  on  a  careful  study  of 
the  symptoms  each  separate  case  presents. 


CHAPTER    YI. 

PUERPERAL  VENOUS  THROMBOSIS  AND  EMBOLISM. 

Puerperal  Thrombosis  and  its  Results. — Under  the  head  of 
Thrombosis  we  may  class  several  important  diseases  connected  with  the 
puerperal  state  which  have  received  far  less  attention  than  they  deserve. 
It  is  only  of  late  years  that  some — we  may  probably  safely  say  the 
majority — of  those  terribly  sudden  deaths  which  from  time  to  time 
occur  after  delivery  have  been  traced  to  their  true  cause — viz.  obstruc- 
tion of  the  right  side  of  the  heart  and  pulmonary  arteries  from  a  blood- 
clot,  either  carried  from  a  distance  or,  as  I  shall  hope  to  show,  formed 
in  situ.  Although  the  result  and,  to  a  great  extent,  the  symptoms  are 
identical  in  both,  still  a  careful  consideration  of  the  history  of  these  two 
classes  of  cases  tends  to  show  that  in  their  causation  they  are  distinct, 
and  that  they  ought  not  to  be  confounded.  (In  the  former  we  have  pri- 
marily a  clotting  of  blood  in  some  part  of  the  peripheral  venous  sys- 
tem, and  the  separation  of  a  portion  of  such  a  thrombus  due  to  changes 
undergone  during  retrograde  metamorphosis  tending  to  its  eventual 
absorption)  In  the  latter  we  have  a  local  deposition  of  fibrin,  the 
result  of  blood-changes  consecpient  on  pregnancy  and  the  puerperal 
state.  The  formation  of  such  a  coagulum  in  vessels  the  complete 
obstruction  of  which  is  incompatible  with  life  explains  the  fatal  results. 
When,  however,  a  coagulum  chances  to  be  formed  in  more  distant  parts 
of  the  circulation,  the  vital  functions  are  not  immediately  interfered 
with,  and  we  have  other  phenomena  occurring,  due  to  tlie  obstruction. 
The  disease  known  as  phlegmasia^  dolens  I  shall  presently  attempt  to 


630  THE  PUERPERAL  STATE. 

show  is  oue  result  of  blood-clot  forming  in  peripheral  vessels.  But 
from  the  evident  and  tangible  symptoms  it  produces  it  has  long  been 
considered  an  essential  and  special  disease,  and  the  general  blood-dyscra- 
sia  which  produces  it,  as  well  as  other  allied  states,  has  not  been  studied 
separately.  I  shall  hope  to  show  that  all  tliese  various  conditions,  dis- 
similar as  they  at  first  sight  appear,  are  very  closely  connected,  and  that 
they  are  in  fact  due  to  a  common  cause;  and  thus,  I  think,  we  shall 
arrive  at  a  clearer  and  more  correct  idea  of  their  true  nature  than  if  we 
looked  upon  them  as  distinct  and  separate  affections,  as  has  been  com- 
monly done.  I  am  aware  that  in  phlegmasia  dolens,  the  pathology  of 
which  has  received  perhaps  more  study  than  that  of  almost  any  other 
puerperal  aflPection,  something  beyond  simple  obstruction  of  the  venous 
system  of  the  affected  limb  is  probably  required  to  account  for  the  pecu- 
liar tense  and  shining  swelling  which  is  so  characteristic.  Whether 
this  be  an  obstruction  of  the  lymphatics,  as  Dr.  Tilbury  Fox  and  others 
have  maintained  with  much  show  of  reason,  or  whether  it  is  some  as 
yet  undiscovered  state,  further  investigation  is  required  to  show.  But 
it  is  beyond  any  doubt  that  the  important  and  essential  part  of  the  dis- 
ease is  the  presence  of  a  thrombus  in  the  vessels ;  and  I  think  it  will  not 
be  difficult  to  prove  that  in  its  causation  and  history  it  is  precisely  similar 
to  the  more  serious  cases  in  which  the  pulmonary  arteries  are  involved. 

It  will  be  well  to  commence  the  study  of  the  subject  by  a  considera- 
tion of  the  conditions  which  in  the  puerperal  state  render  the  blood  so 
peculiarly  liable  to  coagulation,  and  we  may  then  proceed  to  discuss  the 
symptoms  and  results  of  the  formation  of  coagula  in  various  parts  of 
the  circulatory  system. 

Conditions  which  Favor  Thrombosis. — The  researches  of  Vir- 
chow,  Benjamin  Hall,  Humphry,  Richardson,  and  others  have  rendered 
us  tolerably  familiar  with  the  conditions  which  favor  the  coagulation  of 
the  blood  in  the  vessels.  These  are,  chiefly — 1.  A  stagnant  or  arrested 
circulation ;  as,  for  example,  when  the  blood  coagulates  in  the  veins 
which  draw  blood  from  the  gluteal  region  in  old  and  bed-ridden 
people,  or,  as  in  some  forms  of  pulmonary  thrombosis,  in  which  the 
clots  in  the  arteries  are  probably  the  result  of  obstruction  in  the  cir- 
culation through  the  lung-capillaries,  as  in  certain  cases  of  emphysema, 
pneumonia,  or  pulmonary  apoplexy.  2.  A  mechanical  obstruction 
around  which  coagula  form,  as  in  certain  morbid  states  of  the  vessels ; 
or,  a  better  example  still,  secondary  coagula  which  form  around  a 
travelled  embolus  impacted  in  the  pulmonary  arteries.  3.  And  most 
important  of  all,  in  which  the  coagulation  is  the  result  of  some  mox- 
bid  state  of  the  blood  itself.  Examples  of  this  last  condition  are  fre- 
quently met  with  in  the  course  of  various  diseases,  such  as  rheumatism 
or  fever,  in  which  the  quantity  of  fibrin  is  increased  and  the  blood  itself 
is  loaded  with  morbid  material.  Thrombosis  from  this  cause  is  by  no 
means  of  infrequent  occurrence  after  severe  surgical  operations,  especially 
such  as  have  been  attended  with  much  hemorrhage  or  when  the  patient 
is  in  a  weak  and  ansemic  condition.  This  has  been  specially  dwelt  upon 
as  a  not  infrequent  source  of  death  after  operation  by  Fayrer  and  other 
surgeons.^ 

^  Edin.  Med.  Journ.,  March,  1861 ;  Indian  Annals  of  Med.,  July,  1867. 


PUERPERAL    VENOUS  THROMBOSIS  AND  EMBOLISM.       631 

Coagulation  in  the  Puerperal  State. — But  little  consideration  is 
required  to  show  why  thrombosis  plays  so  important  a  part  in  the  puer- 
peral state,  for  there  most  of  the  causes  favoring  its  occurrence  are  pres- 
ent. Probably  there  is  no  other  condition  in  which  they  exist  in  so 
marked  a  degree  or  are  so  frequently  combined.  The  blood  contains 
an  excess  of  fibrin,  which  largely  increases  in  the  latter  months  of 
utero-gestationTuutil,  as  has  been  pointed  out  by  Andral  and  Gavarret, 
it  not  unfrequently  contains  a  third  more  than  the  average  amount 
present  in  the  non-pregnant  state.  As  soon  as  delivery  is  com[)leted 
other  causes  of  blood-dyscrasia  come  into  operation.  Involution  of 
the  largely  hypertrophied  uterus  commences,  and  the  blood  is  charged 
with  a  quantity  of  effete  material,  which  must  be  present  in  greater  or 
less  amount  until  that  process  is  completed,  j  It  is  an  old  observation 
that  phlegmasia  dolens  is  of  very  common  occurrence  in  patients  who 
have  lost  much  blood  during  labor.  Thus  Dr.  Leishman  says  :  "  In 
no  class  of  cases  has  it  been  so  frequently  observed  as  in  women  whose 
strength  has  been  reduced  to  a  low  ebb  by  hemorrhage  either  during  or 
after  labor ;  and  this  no  doubt  accounts  for  the  observation  made  by 
Merrimau,  that  it  is  relatively  a  common  occurrence  after  placenta 
prsevia." '  An  examination  of  the  cases  in  which  death  results  from 
pulmonary  thrombosis  shows  the  same  facts,  as  in  a  large  proportion 
of  them  severe  post-partum  hemorrhage  has  occurred.  The  exhaus- 
tion following  the  excessive  losses  so  common  after  labor  must  of  itself 
strongly  predispose  to  thrombosis ;  and,  indeed,  loss  of  blood  has  been 
distinctly  pointed  out  by  Richardson  to  be  one  of  its  most  common  ante- 
cedents. "  There  is,"  he  observes,  "  a  condition  which  has  been  long 
known  to  favor  coagulation  and  fibrinous  deposition.  I  mean  loss  of 
blood  and  syncope  or  exhaustion  during  impoverished  states  of  the 
body." 

Since,  then,  so  many  of  the  predisposing  causes  of  thrombosis  are 
present  in  the  puerperal  state,  it  is  hardly  a  matter  of  astonishment 
that  it  should  be  of  frequent  occurrence  or  that  it  should  lead  to  con- 
ditions of  serious  gravity.  And  yet  the  attention  of  the  profession 
has  been  for  the  most  part  limited  to  a  study  of  one  only  of  the  results 
of  this  tendency  to  blood-clotting  after  delivery,  no  doubt  because  of 
its  comparative  frequency  and  evident  symptoms.  True,  the  balance 
of  professional  opinion  has  lately  held  that  phlegmasia  dolens  is  chiefly 
the  result  of  some  morbid  condition  of  the  blood,  producing  plugging 
of  the  veins ;  but  the  wider  view  which  I  am  attempting  to  maintain, 
which  would  bring  this  disease  into  close  relation  with  the  more  rarely 
observed  but  infinitely  important  obstructions  of  the  pulmonary  arteries, 
has  scarcely,  if  at  all,  been  insisted  on.  Doubtless,  further  investigation 
will  show  that  it  is  not  in  these  parts  of  the  venous  system  alone  that 
puerperal  thrombosis  occurs ;  but  the  symptoms  and  effects  of  venous 
obstruction  elsewhere,  important  though  they  may  be,  are  unknown. 

Distinction   between   Thrombosis   and  Embolism. — I   propose, 

then,   to  describe  the  symptoms  and   pathology  of  blood-clot   in   the 

right  side  of  the  heart  and  pulmonary  artery.     It  may  be  useful  here 

to  repeat  that  this  is  essentially  distinct  from  embolism  of  the  same 

^  Leishman,  System  of  Obstdrics,  p.  720,  2d  ed.,  1S7G. 


632       /^  ^         fHE  PUERPERAL  STATE. 

parts.  The  lattei^is  obstruction  due  to  the  impaction  of  a  sepa- 
rated portion  of  a  tnrombus  formed  elsewhere,  and  for  its  production 
it  is  essential  that  thrombosis  should  have  preceded  it.  Embolism  is, 
in  fact,  an  accident  of  thrombosis,  not  a  primary  affection.  The  con- 
dition we  are  now  discussing  I  hold  to  be  primary,  precisely  similar  in 
its  causation  to  the  venous  obstruction  which  in  other  situations  gives 
rise  to  phlegmasia  dolens. 

At  the  threshold  of  this  inquiry  we  have  to  meet  the  objection,  started 
by  several  w'ho  have  written  on  this  subject,^  that  spontaneous  coagula- 
tion of  the  blood  in  the  right  side  of  the  heart  and  pulmonary  arteries 
is  a  mechanical  and  physiological  impossibility.  This  was  the  view  of 
VirchoM^,  who  with  his  followers  maintained  that  whenever  death  from 
pulmonary  obstruction  occurred  an  embolus  was  of  necessity  the  start- 
ing-point of  the  malady  and  the  nucleus  round  which  secondary  deposi- 
tion of  fibrin  took  place.  Virchow  holds  that  the  primary  factor  in 
thrombosis  is  a  stagnant  state  of  the  blood,  and  that  the  impulse 
imparted  to  the  blood  by  the  right  ventricle  is  of  itself  sufficient  to 
prevent  coagulation.  It  is  to  be  observed  that  these  objections  are 
purely  theoretical.  Without  denying  that  there  is  considerable  force 
in  the  arguments  adduced,  I  think  that  the  clinical  history  of  these 
cases  strongly  favors  the  view  of  spontaneous  coagulation ;  and  I 
would  apply  to  the  theoretical  objections  advanced  the  argument  used 
by  one  of  their  strongest  upholders  with  regard  to  another  disputed 
point :  "  Je  prefere  laisser  la  parole  aux  faits,  car  devant  eux  la  theorie 
s'incline."  ^ 

The  anatomical  arrangement  of  the  pulmonary  arteries  shows  how 
spontaneous  coagulation  may  be  favored  in  them ;  for,  as  Dr.  Hum- 
phry has  pointed  out,^  "  the  artery  breaks  up  at  once  into  a  number 
of  branches  which  radiate  from  it  at  different  angles  to  the  several  parts 
of  the  lungs.  Consequently,  a  large  extent  of  surface  is  presented  to 
the  blood,  and  there  are  numerous  angular  projections  into  the  currents; 
both  which  conditions  are  calculated  to  induce  the  spontaneous  coagula- 
tion of  the  fibrin."  We  know  also  that  thrombosis  generally  occurs  in 
patients  of  feeble  constitution,  often  debilitated  by  hemorrhage,  in  whom 
the  action  of  the  heart  is  much  weakened.  These  facts  of  themselves 
go  far  to  meet  the  objections  of  those  who  deny  the  possibility  of  spon- 
taneous coagulation  at  the  roots  of  the  pulmonary  arteries. 

Results  of  Post-mortem  Examinations. — The  records  of  post- 
mortem examinations  show  also  that  in  many  of  the  cases  the  right 
side  of  the  heart,  as  well  as  the  larger  branches  of  the  pulmonary 
arteries,  contained  firm,  leathery,  decolorized,  and  laminated  coagula, 
which  could  not  have  been  recently  formed.  The  advocates  of  the 
purely  embolic  theory  maintain  that  these  are  secondary  coagula 
formed  round  an  embolus.  But  surely  the  mechanical  causes  which 
are  sufficient  to  prevent  spontaneous  deposition  of  fibrin  would  also 
suffice  to  prevent  its  gathering  round  an  embolus;  unless,  indeed,  the 
obstruction  w^as  sufficient  to  arrest  the  circulation  altogether,  when 
death  would  occur  before  there  was  any  time  for  a  secondary  deposit. 

^  See  especially  Bertin,  Des  Embolies,  p.  46  et  seq.         ^  Bertin,  Des  Embolies,  p.  149. 
*  Humphry,  On  the  Coagulation  of  the  Blood  in  the  Venous  System  during  Life. 


PUERPERAL   VENOUS  THROMBOSIS  AND  EMBOLISM.       633 

Before  we  can  admit  the  possibility  of  embolism  we  must  have  at  least 
one  factor — that  is,  thrombosis — in  a  peripheral  vessel  from  which  an 
embolus  can  come.  In  many  of  the  recorded  cases  nothing  of  the 
kind  was  found,  and  although,  as  is  argued,  this  may  have  been  over- 
looked, yet  such  an  oversight  can  hardly  always  have  been  made. 

The  strongest  argument,  however,  in  favor  of  the  spontaneous  origin 
of  pulmonary  thrombosis  is  one  which  I  originally  pointed  out  in  a 
series  of  papers  "On  Thrombosis  and  Embolism  of  the  Pulmonary 
Artery  as  a  Cause  of  Death  in  the  Puerperal  State."  ^  I  there  showed, 
from  a  careful  analysis  of  25  cases  of  sudden  death  after  delivery  in 
which  accurate  post-mortem  examinations  had  been  made,  that  cases  of 
spontaneous  thrombosis  and  embolism  may  be  divided  from  each  other 
by  a  clear  line  of  demarcation,  depending  on  the  period  after  delivery 
at  which  the  fatal. result  occurs.  In  7  out  of  these  cases  there  was  dis- 
tinct evidence  of  embolism,  and  in  them  death  occurred  at  a  remote 
period  after  delivery ;  in  none  before  the  nineteenth  day.  This  con- 
trasts remarkably  with  the  cases  in  which  the  post-mortem  examination 
afforded  no  evidence  of  embolism.  These  amount  to  15  out  of  25,  and 
in  all  of  them,  with  one  exception,  death  occurred  before  the  fourteenth 
day,  often  on  the  second  or  third.  The  reason  of  this  seems  to  be  that 
in  the  former  time  is  required  to  admit  of  degenerative  changes  taking 
place  in  the  deposited  fibrin  leading  to  separation  of  an  embolus;  while 
in  the  latter  the  thrombosis  corresponds  in  time,  and  to  a  great  extent, 
no  doubt,  also  in  cause,  to  the  original  peripheral  thrombosis  from  which, 
in  the  former,  the  embolus  was  derived.  Many  cases  I  have  since  col- 
lected illustrated  the  same  rule  in  a  very  curious  and  instructive  way. 

Another  clinical  fact  I  have  observed  points  to  the  same  conclusion. 
In  one  or  two  cases  distinct  signs  of  pulmonary  obstruction  have  shown 
themselves  without  proving  immediately  fatal,  and  shortly  afterward 
peripheral  thrombosis,  as  evidenced  by  phlegmasia  dolens  of  one 
extremity,  has  commenced.  Here  the  peripheral  thrombosis  obviously 
followed  the  central,  both  beiug  produced  by  identical  causes,  and  the 
order  of  events  necessary  to  uphold  the  purely  embolic  theory  was 
reversed. 

I  hold,  then,  that  those  who  deny  the  possibility  of  spontaneous 
coagulation  in  the  heart  and  pulmonary  arteries  do  so  on  insufficient 
grounds,  and  that  we  may  consider  it  to  be  an  occurrence,  rare  no 
doubt,  but  still  sufficiently  often  met  with,  and  certainly  of  sufficient 
importance,  to  merit  very  careful  study. 

History. — Dr.  Charles  D.  Meigs  of  Philadelphia  was  one  of  the  firet 
to  direct  attention  to  spontaneous  coagulation  of  the  blood  in  the  right 
side  of  the  heart  and  pulmonary  arteries  as  a  cause  of  sudden  death  in 
the  puerperal  state.  The  occurrence  itself,  however,  has  been  carefully 
studied  by  Paget,  whose  paper  was  ]3ublished  in  1855,  four  years 
before  Meigs  wrote  on  the  subject.^  It  is  true  that  none  of  Paget's 
cases  happened  after  delivery,  but  he  none  the  less  clearly  apprehended 
the  nature  of  the  obstruction.     In  1855,  Hecker  ^  attributed  the  majority 

'  Lancet,  1867. 

"^ Medico-Chir.  Trans.,  vol.  xxvii.  p.  162,  and  vol.  xxviii.  p.  352  ;  Philadelphia  MeiUcal 
Examiner,  1849.  '^Deutsche  Klinik,  1855. 


634  THE  PUERPERAL  STATE. 

of  these  cases  to  embolism  proper,  and  since  that  date  most  authors  have 
taken  the  same  view,  believing  that  spontaneous  coagulation  only  occurs 
in  exceptional  cases,  such  as  those  in  ^vhich,  on  account  of  some  obstruc- 
tion in  the  lung  or  of  the  debility  of  the  last  few  hours  before  death,  coag- 
ula  form  in  the  smaller  ramifications  of  the  pulmonary  arteries  and 
gradually  creep  backward  toward  the  heart. 

Symptoms  of  Pulmonary  Obstruction. — The  symptoms  can  hardly 
be  mistaken,  and  there  seems  to  be  no  essential  difference  between  the 
symptomatology  of  spontaneous  and  embolic  obstructions,  so  that  the 
same  description  will  suffice  for  both.  In  a  large  proportion  of  cases 
the  attack  comes  on  with  an  appalling  suddenness  which  forms  one  of 
its  most  striking  characteristics.  Nothing  in  the  condition  of  the  patient 
need  have  given  rise  to  the  least  suspicion  of  impending  mischief,  when 
aU  at  once  an  intense  and  horrible  dyspnoea  comes  on :  she  gasps  and 
struggles  for  breath,  tears  off  the  coverings  from  her  chest  in  a  vain 
endeavor  to  get  more  air,  and  often  dies  in  a  few  minutes,  long  before 
medical  aid  can  be  had,  with  all  the  symptoms  of  asphyxia.  The  mus- 
cles of  the  face  and  thorax  are  violently  agitated  in  the  attempt  to  oxy- 
genate the  blood,  and  an  appearance  closely  resembling  an  epileptic  con- 
vulsion may  be  presented.  The  face  may  be  either  pale  or  deeply 
cyanosed.  Thus  in  one  case  I  have  elsewhere  recorded,  which  was  an 
undoubted  example  of  true  embolism,  Mr.  Pedler,  the  resident  accouch- 
eur at  King's  College  Hospital,  who  was  present  during  the  attack, 
writes  of  the  patient :  ^  "  She  was  suffering  from  extreme  dyspnoea,  the 
countenance  was  excjessively  pale,  her  lips  white,  the  face  generally 
expressing  deep  anxiety."  In  another,  which  was  probably  an  example 
of  spontaneous  thrombosis^  occurring  on  the  twelfth  day  after  delivery, 
it  is  stated  :  "  The  face  had  assumed  a  livid  purple  hue,  which  was  so 
remarkable  as  to  attract  the  attention  both  of  the  nurse  and  of  her 
mother,  who  was  with  her."  The  extreme  embarrassment  of  the  cir- 
culation is  shown  by  the  tumultuous  and  irregular  action  of  the  heart 
in  its  endeavor  to  send  the  venous  blood  through  the  obstructed  pul- 
monary arteries.  Soon  it  gets  exhausted,  as  shown  by  its  feeble  and 
fluttering  beat.  The  pulse  is  thread-like  and  nearly  imperceptible,  the 
respirations  short  and  hurried,  but  air  may  be  heard  entering  the  lungs 
freely.  The  intelligence  during  the  struggle  is  unimpaired,  and  the 
dreadful  consciousness  of  impending  death  adds  not  a  little  to  the 
patient's  sufferings  and  to  the  terror  of  the  scene.  Such  is  an  imperfect 
account  of  the  symptoms  gathered  from  the  record  of  what  has  been 
observed  in  fatal  cases.  It  will  be  readily  understood  Mhy,  in  the 
presence  of  so  sudden  and  awful  an  attack,  symptoms  have  not  been 
recorded  with  the  accuracy  of  ordinary  clinical  observation. 

Is  Recovery  Possible  ? — A  question  of  great  practical  interest 
which  has  been  entirely  overlooked  by  Avriters  on  the  subject  is.  Have 
we  any  ground  for  supposing  that  there  is  a  possibility  of  recovery  after 
symptoms  of  pulmonary  obstruction  have  developed  themselves  ?  That 
such  a  result  must  be  of  extreme  rarity  is  beyond  question,  but  I  have 
little  doubt  that  in  some  few  cases,  entirely  inexplicable  on  any  other 
hypothesis,  life  is  prolonged  until  the  coagulura  is  absorbed  and  the  pul- 

^  Brit.  Med.  Journ.,  1869,  vol.  i.  p.  282.  ^  Obst.  Trans.,  1871,  vol.  xii.  p.  194. 


PUERPERAL    VENOUS  THROMBOSIS  AND  EMBOLISM.       G35 

monaiy  circulation  restored.  lu  order  to  admit  of  this  it  is  of  course 
essential  that  the  obstruction  be  not  sufficient  to  ])revent  the  passage  of 
a  certain  quantity  of  blood  to  the  lungs  to  carry  on  the  vital  functions. 
The  history  of  many  cases  tends  to  show  that  the  obstructing  clot  was 
present  for  a  considerable  time  before  death,  and  that  it  was  only  when 
some  sudden  exertion  was  made,  such  as  rising  from  bed  or  the  like, 
calling  for  an  increased  supply  of  blood  which  could  not  pass  through 
the  occluded  arteries,  that  fatal  symptoms  manifested  themselves.  This 
was  long  ago  pointed  out  by  Paget,'  who  says:  "The  case  proves  that 
in  certain  circumstances  a  great  part  of  the  pulmonary  circulation  may 
be  arrested  in  the  course  of  a  week  (or  a  few  days  more  or  less)  without 
immediate  danger  to  life  or  any  indication  of  what  had  happened." 
And  after  referring  to  some  illustrative  cases,  "  Yet  in  all  these  cases 
the  characters  of  the  clots  by  which  the  pulmonary  arteries  were 
obstructed  showed  plainly  that  they  had  been  a  week  or  more  in  the 
process  of  formation."  If  we  admit  the  possibility  of  the  continuance 
of  life  for  a  certain  time,  we  must,  I  think,  also  admit  the  possibility, 
in  a  few  rare  cases,  of  eventual  complete  recovery.  What  is  required 
is  time  for  the  absorption  of  the  clot.  In  the  peripheral  venous  system 
coagula  are  constantly  removed  by  absorption.  So  strong,  indeed,  is 
the  tendency  to  this  that  Humphry  observes  with  regard  to  it,  "  It 
appears  that  the  blood  is  almost  sure  to  revert  to  its  natural  channel  iu 
process  of  time."^  If,  then,  the  obstruction  be  only  partial,  if  suffi- 
cient blood  pass  to  keep  the  patient  alive,  and  a  sudden  supply  of  oxy- 
genated blood  is  not  demanded  by  any  exertion  which  the  embarrassed] 
circulation  is  unable  to  meet,  it  is  not  inconceivable  that  the  patienj 
may  live  until  the  obstruction  is  removed. 

Illustrative  Cases. — Such  I  believe  to  be  the  only  explanation  of 
certain  cases,  some  of  which,  on  any  other  hypothesis,  it  is  impossible 
to  understand.  The  symptoms  are  precisely  those  of  pulmonary  obstruc- 
tion, and  the  description  I  have  given  above  may  be  applied  to  them  in 
every  particular ;  and  after  repeated  paroxysms,  each  of  which  seems  to 
threaten  immediate  dissolution,  an  eventual  recovery  takes  place.  What, 
then,  I  am  entitled  to  ask,  can  the  condition  be  if  not  that  which  I  sug- 
gest "?  As  the  question  I  am  considering  has  never,  so  far  as  I  am 
aware,  been  treated  of  by  any  other  writer,  I  may  be  permitted  to  state 
very  briefly  the  facts  of  one  or  two  of  the  cases  on  which  I  found  my 
argument,  some  of  which  I  have  already  published  in  detail  else- 
where : 

K.  H ,  delicate  young  lady.     Labor  easy.     First  child.     Profuse   post-partum 

hemorrhage.  Did  well  until  the  seventh  day,  during  the  whole  of  which  she  felt 
weak.  Same  day  an  alarming  attack  of  dyspnoea  came  on.  For  several  days  she 
remained  in  a  very  critical  condition,  the  slightest  exertion  bringing  on  the  attacks. 
A  slight  blowing  murmur  heard  for  a  few  days  at  the  base  of  the  heart,  and  then  dis- 
appeared. For  two  months  patient  remained  in  the  same  state.  As  long  as  she  was 
in  the  recumbent  position  she  felt  pretty  comfortable,  but  any  attempt  at  sitting  up  in 
bed  or  any  unusual  exertion  immediately  brought  on  the  embarrassed  respiration. 
During  all  this  time  it  was  found  necessary  to  administer  stiiiiulants  profusely  to  ward 
ofl"  the  attacks.     Eventually  the  patient  recovered  completely. 

Q.  F ,  set.  44,  mother  of  twelve  children.     Confined  on  July  6.     On  the  eleventh 

day  she  went  to  bed  feeling  well.     There  was  no  swelling  or  discomfort  of  any  kind 

'  Op.  ciL,  p.  358.  ^  Med.-Chir.  Trans.,  vol.  xxvii.  p.  14. 


636  THE  PUERPERAL  STATE. 

about  the  lower  extremities  at  this  time.  About  half-past  three  a.m.  she  was  sitting  up 
in  bed  when  she  was  suddenly  attacked  with  an  indescribable  sense  of  oppression  in 
the  chest,  and  fell  back  in  a  semi-unconscious  state,  gasping  for  breath.  She  remained 
in  a  very  critical  condition,  with  the  same  symj^toms  of  embarrassed  respiration,  for 
three  days,  when  they  gradually  passed  away.  Two  days  after  the  attack  of  phlegmasia 
dolens  came  on,  the  leg  swelled,  and  remained  so  for  several  months. 

This  case  is  an  example  of  the  fact  I  have  ah*eadj  referred  to,  of 
phlegmasia  dolens  coraiug  on  after  the  symj)toms  of  pulmonary 
obstruction  had  manifested  themselves,  the  inference  being  that  both 
depended  on  similar  causes  operating  on  two  distinct  parts  of  the  circu- 
latory system. 

C.  H ,  set.  24.     Confined  of  her  first  child  on  August  20, 1 867.     Thirty  hours  after 

delivery  she  complained  of  great  weakness  and  dyspnoea.  This  was  alleviated  by  the 
treatment  employed,  but  on  the  ninth  day,  after  making  a  sudden  exertion,  the  dyspnoea 
returned  with  increased  violence,  and  continued  unabated  until  I  saw  the  patient  on 
September  4,  fourteen  days  after  her  confinement.  The  following  are  the  notes  of  her 
condition,  made  at  the  time  of  the  visit :  "  I  found  her  sitting  on  the  sofa  propped  up 
with  pillows,  as  she  said  she  could  not  breathe  in  the  recumbent  position.  The  least 
excitement  or  talking  brought  on  the  most  aggravated  dyspnoea,  which  was  so  bad  as 
to  threaten  almost  instant  death.  Her  sufferings  during  these  paroxysms  were  terrible 
to  witness.  She  panted  and  struggled  for  breath  and  her  chest  heaved  with  short, 
gasping  respirations.  She  could  not  even  bear  any  one  to  stand  in  front  of  her,  wav- 
ing them  away  with  her  hand  and  calling  for  more  air.  These  attacks  were  very  fre- 
quent, and  were  brought  on  by  the  most  trivial  causes.  She  talked  in  a  low  suppressed 
voice,  as  if  she  could  not  spare  breath  for  articulation.  On  auscultation  air  was  found 
to  enter  the  lungs  freely  in  every  direction,  both  in  front  and  behind.  Immediately 
over  the  site  of  the  pulmonary  arteries  there  M-as  a  distinct  harsh,  rasping  murmur, 
confined  to  a  very  limited  space  and  not  propagated  either  upward  or  downward.  The 
heart-sounds  were  feeble  and  tumultuous."  These  symptoms  led  me  to  diagnose  pul- 
monary obstruction,  and  I  of  course  gave  a  most  unfavorable  prognosis,  but  to  my  great 
surprise  the  patient  slowly  recovered.  I  saw  her  again  six  weeks  later,  when  her  heart- 
sounds  were  regular  and  distinct  and  the  murmur  had  completely  disappeared. 

E.  E ,  £et.  42,  was  confined  for  the  first  time  on  November  5,  1873,  in  the  sixth 

month  of  utero-gestation.  She  had  severe  post-jDartum  hemorrhage,  depending  on 
partially  adherent  placenta,  which  was  removed  artificially.  She  did  perfectly  well 
until  the  fourteenth  day  after  delivery,  when  she  was  suddenly  attacked  with  intense 
dyspncea,  aggravated  in  paroxysms.  Pulse  pretty  full,  130,  but  distinctly  intermittent. 
Air  entered  lungs  freely.  The  heart's  action  was  fluttering  and  irregular,  and  at  the 
juncture  of  the  fourth  and  fifth  ribs  with  the  sternum  there  was  a  loud  blowing  systolic 
murmur.  This  was  certainly  non-existent  before,  as  tlie  heart  had  been  carefully  aus- 
cultated before  administering  chloroform  during  labor.  For  two  days  the  patient 
remained  in  the  same  state,  her  death  being  almost  momentarily  expected.  On  the 
21st — that  is,  two  days  after  the  appearance  of  the  chest-symptoms — phlegmasia  dolens 
of  a  severe  kind  developed  itself  in  the  right  thigh  and  leg.  She  continued  in  the 
same  state  for  many  days,  lying  more  or  less  tranquilly,  but  having  paroxysms  of  the 
most  intense  apncea,  varying  from  two  to  six  or  eight  in  the  twenty-four  hours.  Xo 
one  who  saw  her  in  one  of  these  could  have  expected  her  to  live  through  it.  Shortly 
after  the  first  appearance  of  the  paroxysms  it  was  observed  that  the  cellular  tissue  of 
the  neck  and  part  of  the  face  became  swollen  and  oedematous,  giving  an  appearance 
not  unlike  that  of  phlegmasia  dolens.  The  attacks  were  always  relieved  by  stimulants. 
These  she  incessantly  called  for,  declaring  that  she  felt  they  kept  her  alive.  During 
all  this  time  the  mind  was  clear  and  collected.  The  pulse  varied  from  110  to  130; 
respirations  about  60;  temperature  101°  to  102.5°.  By  slow  degrees  tlie  patient  seemed 
to  be  rallying.  The  paroxysms  diminished  in  number,  and  after  December  1st  she 
never  had  another  and  the  breathing  became  free  and  easy.  The  pulse  fell  to  80,  and 
the  cardiac  murmur  entirely  disa23peared.  The  patient  remained,  however,  verj'  weak 
and  feeble,  and  the  debility  seemed  to  increase.  Toward  the  second  week  in  December 
she  became  delirious,  and  died,  apparently  exhausted,  without  any  fresh  chest-symp- 
toms, on  the  19th  of  that  month.     No  post-mortem  examination  was  allowed. 

I  have  narrated  tliis  case,  although  it  terminated  fatally,  because  I 
hold  it  to  be  one  of  the  class  I  am  considering.     The  death  was  cer- 


PUERPERAL    VENOUS  THROMBOSIS  AND  EMBOLISM.       637 

tainly  not  due  to  the  obstruction,  all  symptoms  of  which  had  dis- 
appeared, but  apparently  to  exhaustion  from  the  severity  of  the 
former  illness.  It  illustrates,  too,  the  simultaneous  appearance  of 
symptoms  of  pulmonary  obstruction  and  peripheral  thrombosis.  The 
swelling  of  the  neck  was  a  curious  symptom  which  has  not  been 
recorded  in  any  other  cases,  and  may  possibly  be  a  further  proof  of 
the  analogy  between  this  condition  and  phlegmasia  dolens. 

Such  Cases  can  only  Depend  on  Pulmonary  Obstruction. — Xow, 
it  may  of  course  be  argued  that  these  cases  do  not  prove  my  thesis,  inas- 
much as  I  only  assume  the  presence  of  a  coagulum.  But  I  may  fairly 
ask,  in  return,  what  other  condition  could  possibly  explain  the  symp- 
toms? They  are  precisely  those  which  are  noticed  in  death  from 
undoubted  pulmonary  obstruction.  No  one  seeing  one  of  them,  or 
even  reading  an  account  of  the  symptoms  while  ignorant  of  the  result, 
could  hesitate  a  single  instant  in  the  diagnosis.  Surely,  then,  the  infer- 
ence is  fair  that  they  depended  on  the  same  cause.  In  the  very  nature 
of  things  my  hypothesis  cannot  be  verified  by  post-mortem  examina- 
tion ;  but  there  is  at  least  one  case  on  record  in  which,  after  similar 
symptoms,  a  clot  was  actually  found.  The  case  is  related  by  Dr. 
Richardson.^  It  was  that  of  a  man  who  for  weeks  had  symptoms 
precisely  similar  to  those  observed  in  the  cases  I  have  narrated.  In 
one  of  his  agonizing  struggles  for  breath  he  died,  and  after  death  it 
was  found  "  that  a  fibrinous  band,  having  its  hold  in  the  ventricle, 
extended  into  the  pulmonary  artery."  This  observation  proves  to  a 
certainty  that  life  may  continue  for  weeks  after  deposition  of  a  coagu- 
lum ;  and,  moreover,  this  condition  w^as  precisely  what  we  should  antici- 
pate, since  of  course  the  obstructing  coagulum  must  necessarily  be  small, 
otherwise  the  vital  functions  would  be  immediately  arrested. 

Cardiac  Murmurs  in  Pulmonary  Obstruction. — There  is  a  symp- 
tom noted  in  two  of  the  above  cases,  and  to  a  less  extent  in  a  third, 
which  has  not  been  mentioned  in  any  account  of  fatal  cases  occurring 
after  delivery — viz.  a  murmur  over  the  site  of  the  pulmonary  arteries. 
It  is  a  sign  we  should  naturally  expect,  and  very  possibly  it  would  be 
met  with  in  fatal  cases  if  attention  were  particularly  directed,  to  the  ■ 
point.  In  both  these  instances  it  was  exceedingly  well  marked,  and 
in  both  it  entirely  disappeared  when  the  symptoms  abated.  The 
probability  of  such  a  murmur  being  audible  in  cases  of  thrombosis 
of  the  pulmonary  artery  has  been  recognized  by  one  of  our  highest 
authorities  in  cardiac  disease,  who  actually  observed  it  in  a  non-puer- 
peral case.  In  the  last  edition  of  his  work  on  diseases  of  the  heart 
Dr.  Walshe  ^  says :  "  The  only  physical  condition  connected  with  the 
vessel  itself  would  probably  be  systolic  basic  murmur  following  the 
course  of  the  pulmonary  main  trunk  and  of  its  immediate  divisions 
to  the  left  and  right  of  the  sternum.  This  sign  I  most  certainly  heard 
in  an  old  gentleman  Mdiose  life  was  brought  to  a  sudden  close  in  the 
course  of  an  acute  affection  by  coagulation  in  the  pulmonary  artery, 
and  to  a  moderate  extent  in  the  right  ventricle. 

Similar  cases  have  probably  been  overlooked  or  misinterpreted.   Many 

1  Clinical  Essays,  p.  224  et  seq. 

2  Walshe,  On  Diseases  of  the  Heart,  4th  ed.,  1873. 


638  Till-:  PUERPERAL  STATE. 

setiii  to  liave  heoii  attril>uted  to  shock,  in  the  ahsencc  ol"  a  better  expla- 
nation— a  condition  to  Mliidi  tliey  bear  no  kind  of"  resemblance. 

Causes  of  Death. — 'i'lie  precise  mode  of  death  in  pulmonary 
obstruction,  whether  dependent  ou  thrombosis  or  embolism,  has  given 
rise  to  considerable  diliercnce  of  opinion,  Vircliow  attributes  it  to 
syncope,^  depending  on  stoppage  of  the  cardiac  contraction.  Panum,^ 
on  the  other  hand,  contests  this  view,  maintaining  that  the  heart  con- 
tinues to  beat  even  after  all  signs  of  life  have  ceased.  Certainly, 
tumultuous  and  irregular  j)ulsati()ns  of  the  heart  are  prominent  symp- 
toms in  most  of  the  recorded  cases,  and  are  not  reconcilable  with  the 
idea  of  syncope.  Panum's  own  theory  is  that  death  is  the  result  of 
cerebral  ansemia.  Paget  seems  to  think  that  the  mode  of  death  is 
altogether  peculiar,  in  some  respects  resembling  synco])e,  in  others 
aufemia.  Bertin,  who  has  discussed  the  subject  at  great  length, 
attributes  the  fatal  result  purely  to  asphyxia.  The  condition,  indeed, 
is  in  all  respects  similar  to  that  state,  the  oxygenation  of  the  blood 
being  prevented,  not  because  air  cannot  get  to  the  blood,  but  because 
blood  cannot  get  to  the  air.  The  symptoms  also  seemed  best  explained 
by  this  theory :  the  intense  dyspnoea,  the  terrible  struggle  for  air,  the 
preservation  of  intelligence,  the  tumultuous  action  of  the  heart,  are 
certainly  not  characteristic  either  of  syncope  or  anaemia. 

Post-mortem  Appearances  of  Clots. — The  anatomical  character 
of  the  clots  seems  to  vary  considerably.  Ball,  by  whom  they  have 
been  most  carefully  described,  believes  that  they  generally  commence  in 
the  smaller  ramifications  of  the  arteries,  extending  backward  toward 
the  heart  and  filling  the  vessels  more  or  less  completely.  Toward  its 
cardiac  extremity  the  coagulum  terminates  in  a  roimded  head,  in  which 
respect  it  resembles  those  spontaneously  formed  in  the  peripheral  veins. 
It  is  non-adherent  to  the  coats  of  the  vessels,  and  the  blood  circulates, 
when  it  can  do  so  at  all,  between  it  and  the  vascular  walls.  Such  clots 
are  white,  dense,  and  of  a  homogeneous  structure,  consisting  of  layers 
of  decolorized  fibrin,  firm  at  the  periphery,  where  the  fibrin  has  been 
most  recently  deposited,  and  softened  in  the  centre,  where  amylaceous 
or  fatty  degeneration  has  commenced.  Ball  maintains  that  if  the  coag- 
ulum have  commenced  in  the  larger  branches  of  the  arteries,  it  must 
have  first  begun  in  tlie  ventricle  and  extended  into  them.  According 
to  Humphry,  the  same  changes  take  })lacc  in  pulmonary  as  in  peri})h- 
eral  thrombi,  and  they  may  become  adherent  to  the  walls  of  the  vessels 
or  converted  into  threads  or  bands.  AMien  the  obstruction  is  due  to 
embolism,  provided  the  case  is  a  well-marked  one  and  the  embolus  of 
some  size,  the  appearances  presented  are  different.  We  have  no  longer 
a  laminated  and  decjolorized  coagulum  with  a  rounded  head,  similar  to 
a  peripheral  thrombus.  The  obstruction  in  this  case  generally  takes 
place  at  the  point  of  bifurcation  of  the  artery,  and  we  there  meet  with 
a  grayish-white  mass,  contrasting  remarkably  with  the  more  recently 
deposited  fibrin  before  and  behind  it.  It  may  be  that  the  form  of  the 
embolus  shows  that  it  has  recently  been  separated  from  a  clot  elsewher.e, 
and  in  many  cases  it  has  been  possible  to  fit  the  travelled  ])ortion  to  the 
extremity  of  the  clot  from  which  it  has  been  broken.     Vs^c  may  also, 

1  Gesamm.  Abhandi,  1862,  p.  316.  '^  Vircfmv's  Arckiv,  1863. 


PUERPERAL    VENOrrS   THROMBOSIS  AND    EM  HOLISM.       030 

perliaps,  find  that  tli(!  ombolus  has  undergone  an  amount  of  lelmorade 
metanioi-phosis  con-esponding  with  that  of  the  peripheral  thromljus 
from  which  we  suppose  it  to  have  come,  but  differing  from  that  of  the 
more  recently  dejiosited  fibrin  around  it.  It  must  be  admitted,  how- 
ever, that  the  anatomical  peculiarities  of  the  coagula  will  by  no  means 
always  enable  us  to  trace  them  to  their  true  origin.  In  many  cases 
emboli  may  escai)e  detection  from  their  smallness  or  from  the  quantity 
of  fibrin  surrounding  them. 

Treatment. — But  few  words  need  be  said  as  to  the  treatment  of  pul- 
monary obstruction.  In  a  large  majority  of  cases  the  fatal  result  so 
rapidly  follows  the  appearance  of  the  symptoms  that  no  time  is  given 
us  even  to  make  an  attempt  to  alleviate  the  patient's  sufferings.  Should\ 
we  meet  with  a  case  not  inmiediately  fatal,  it  seems  that  there  are  but! 
two  indications  of  treatment  affording  the  slightest  rational  ground  of  I 
hope : 

1.  To  keep  the  patient  alive  by  the  administration  of  stimulants — 
brandy,  ether,  ammonia,  and  the  like — to  be  repeated  at  intervals  cor- 
responding to  the  intensity  of  the  paroxysms  and  the  results  produced. 
In  the  cases  I  have  above  narrated  iu  which  recovery  ensued  this  took 
the  place  of  all  other  medication.  Possibly  leeches  or  dry  cupping  to 
the  chest  might  prove  of  some  service  iu  relieving  the  circulation. 

2.  To  enjoin  the  most  absolute  j^d_comple^tej;ejj  The  object  of 
this  is  evident.  The  only  chance  for  the  patient  seems  to  be  that  the 
vital  functions  should  be  carried  on  until  the  coagulura  has  been 
absorbed,  or  at  least  until  it  has  been  so  much  lessened  in  size  as  to 
admit  of  blood  passing  it  to  the  lungs.  The  slightest  movements  may 
give  rise  to  a  fatal  paroxysm  of  dyspnoea  from  the  increased  supply  of 
oxygenated  blood  required.  It  must  not  be  forgotten  that  in  a  large 
proportion  of  cases  death  immediately  followed  some  exertion  in  itself 
trivial,  such  as  rising  out  of  bed.  Too  much  attention,  then,  cannot  be 
given  to  this  point.  The  patient  should  be  absolutely  still ;  she  should 
be  fed  with  abundance  of  fluid  food,  such  as  milk,  strong  soups,  aud 
the  like ;  aud  she  should  on  no  account  be  permitted  to  raise  herself  iu 
bed  or  attempt  the  slightest  muscular  exertion.  If  we  are  fortunate 
enough  to  meet  with  a  case  apparently  tending  to  recovery,  these  pre- 
cautions must  be  carried  on  long  after  the  severity  of  the  symptoms  has 
lessened,  for  a  moment's  imprudence  may  suffice  to  bring  them  back  iu 
all  their  original  intensity. 

Bertin,^  indeed,  recommends  a  system  of  treatment  very  different 
from  this.  Iu  the  vain  hope  that  the  violent  effort  induced  may  cause 
the  displacement  of  the  impacted  embolus  (to  which  alone  he  attributes 
pulmonary  obstruction),  he  recommends  the  administration  of  emetics. 
Few,  I  fancy,  will  be  found  bold  enough  to  attempt  so  hazardous  a  plan 
of  treatment. 

Various  drugs  have  been  suggested  iu  these  cases.  Richardson-' 
recommended  ammonia,  a  deficiency  of  wdiich  he  at  that  time  believed 
to  be  the  chief  cause  of  coagulation.  He  has  since  advised  that  liquor 
ammonia?  should  be  given  in  large  doses,  20  minims  every  hour,  in  the 
hope  of  causing  solution  of  the  deposited  fibrin ;  and  he  has  stated  that 

^  Op.  cil.,  p.  393.  ^  Hmrt  Disease  durint/  Pregminci/,  p.  209. 


640  THE  PUERPERAL  STATE. 

he  has  seen  fjood  results  from  the  practice.  Others  advise  the  adminis- 
tration of  alkalies,  in  the  hope  that  thcv  may  favor  absorption.  'J'hc 
best  that  can  be  said  for  them  is  that  they  are  not  likely  to  do  much 
harm. 

Puerperal  Pleuro-pneumonia. — This  is,  perha])s,  the  best  place  to 
mention  an  important  but  little  understood  cla-ss  of  cases  which  I  believe 
to  be  less  uncommon  than  is  generally  supposed.  I  refer  to  severe 
pleuro-pneumonia  occurring  in  connection  with  the  puerperal  state,  but 
not  distinctly  associated  ^vith  septicjcmia.  Two  carefully  observed  cases 
of  this  kind  are  recorded  by  ]MacDonald  occurring  in  his  practice ;  I 
myself  have  met  with  three  very  marked  examples  within  the  past 
three  years,  one  of  which  proved  fatal,  the  other  two  giving  rise  to 
most  serious  illness,  from  which  the  patient  recovered  with  difKculty. 

So  far  as  my  own  observation  goes,  there  are  marked  peculiarities  in 
such  cases  which  clearly  differentiate  them  from  the  ordinary  course  of 
pneumonia.  The  onset  is  sudden  and  unconnected  with  exposure  to 
cold  or  other  cause  of  lung  disease;  there  is  no  definite  crisis,  but  a 
continuous  pyrexia  of  moderate  intensity,  lasting  a  variable  time ;  and 
the  physical  signs  differ  from  those  of  ordinary  pneumonia. 

In  MacDonald's  cases,  as  well  as  in  my  own,  they  were  peculiar  in 
this  respect,  that  there  was  very  slight  crepitation,  marked  rusty 
sputum,  and  a  wooden  dulness,  much  more  intense  than  in  ordinary 
pneumonia,  extending  over  a  large  lung  space,  with  a  very  slight 
entrance  of  air  into  the  lung-tissue,  It  is  also  remarkable  that  a  very 
large  proportion  of  the  cases  were  associated  with  phlegmasia  dolens. 
Thus  it  existed  in  one  of  jSIacDonald's  two  cases,  and  in  two  out  of  my 
own  three.  Like  phlegmasia  dolens,  moreover,  the  disease  generally 
commenced  some  weeks  after  delivery;  my  OAvn  cases,  for  example, 
occurred  respectively  fifteen,  twenty-eight,  and  thirty-five  days  after 
labor.  It  is  difficult  to  believe  that  there  is  not  some  connection  between 
these  two  conditions ;  and  there  is  much  in  their  peculiar  history  to  lead 
to  the  belief  that  such  forms  of  lung  disease  depend,  in  fact,  on  the 
thrombotic  or  embolic  obstruction  of  the  minute  branches  of  the  pul- 
monary arteries,  caused  by  conditions  similar  to  those  which  have  pro- 
duced the  phlebitic  obstructions  in  the  lower  extremities.  In  the 
absence  of  careful  post-mortem  examination  this  hypothesis  is  clearly 
not  susceptible  of  proof.  MacDonald,  while  admitting  that  "a  limited 
thrombosis  of  the  pulmonary  arteries  would  no  doubt  explain  the  facts 
of  the  cases,"  is  rather  inclined  to  "  seek  the  chief  explanation  of  their 
occurrence  in  the  alterations  Mhich  the  pregnant  and  puerperal  condi- 
tions impress  upon  the  blood  and  the  blood  vascular  system." 

I  confess  that  to  my  mind  the  former  hypothesis  is  not  only  the  most 
definite,  but  the  one  which  most  readily  explains  all  the  peculiarities  of 
these  cases.  I  cannot,  however,  do  more  tlian  suggest  it,  in  the  hope 
that  further  observations,  and  especially  carefully  conducted  autopsies, 
may  throw  some  light  on  this  obscure  and  little-studied  subject. 

Treatment. — As  regards  treatment,  it  is  obvious  that  it  must  be  con- 
ducted on  general  principles,  carefully  avoiding  over-severe  measures, 
and  supporting  the  patient  through  a  trial  to  the  system  that  must 
necessarily  be  severe. 


PUERPERAL  ARTERIAL   THROMBOSIS  AND  EMBOLISM.     641 


CHAPTER  VII. 
PUERPERAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM, 

Arterial  Thrombosis  and  Embolism. — The  same  condition  of  the 
blood  M'liieh  so  strongly  predisposes  to  coagulation  in  the  vessels  through 
which  venous  blood  circulates  tends  to  similar  results  in  the  arterial  sys- 
tem. These,  however,  arc  by  no  means  so  common,  and  do  not,  as  a 
rule,  lead  to  such  important  consequences.  The  subject  has  been  but 
little  studied,  and  almost  all  our  knowledge  of  it  is  derived  from  a  very 
interesting  essay  by  Sir  James  Simpson.^  As  I  have  devoted  so  much 
space  to  the  consideration  of  venous  thrombosis  and  embolism,  I  shall 
but  briefly  consider  the  effects  of  arterial  obstruction. 

Causes. — In  a  considerable  number  of  recorded  cases  the  obstruction 
has  resulted  from  the  detachment  of  .vegetations  deposited  on  the  car- 
diac valves,  the  result  of  endocarditis,  either  produced  by  antecedent 
rheumatism  or  as  a  complication  of  the  puerperal  state.  Sometimes  the 
ol)struction  seems  to  depend  on  some  general  blood-dyscrasia,  similar  to 
that  producing  venous  thrombosis,  or  on  some  local  change  in  the  artery- 
itself.  Thus,  Simpson  records  a  case  apparently  produced  by  local 
arteritis  which  caused  acute  gangrene  of  both  lower  extremities,  ending 
fatally  in  the  third  week  after  delivery.  In  other  cases  it  has  been 
attributed  to  coagulation  following  spontaneous  laceration  and  corruga- 
tion of  the  internal  coat  of  the  artery. 

Symptoms. — The  symptoms  of  puerperal  arterial  obstruction  must 
of  course  vary  with  the  particular  arteries  affected.  Those  with  the 
obstruction  of  which  we  are  most  familiar  are  the  cerebral,  the  brachial, 
and  the  femoral.  The  effects  produced  must  also  be  modified  by  the 
size  of  the  embolus  and  the  more  or  less  complete  obstruction  it  pro- 
duces. Thus,  for  example,  if  the  middle  cerebral  artery  be  blocked 
up  entirely,  the  functions  of  those  portions  of  the  brain  suiDplied  by  it 
will  be  more  or  less  completely  arrested,  and  hemiplegia  of  the  oppo- 
site side  of  the  body,  followed  by  softening  of  the  brain-texture,  will 
probably  result.  If  the  nervous  symptoms  be  developed  gradually  or 
increase  in  intensity  after  their  first  appearance,  it  may  be  that  an 
obstruction,  at  first  incomplete,  has  increased  by  the  deposition  of  fibrin 
around  it.  So  the  occasional  sudden  supervention  of  blindness  with 
destruction  of  the  eyeball — cases  of  which  are  recorded  by  Simpson — 
not  improbably  depends  on  the  occlusion  of  the  ophthalmic  artery,  the 
function  of  the  organ  de[)cnding  on  its  supply  through  the  single  artery. 
The  effects  of  obstruction  of  the  visceral  arteries  in  tlu'  puerperal  state 
are  entirely  unknown,  but  it  is  far  from  unlikely  that  further  investiga- 
tion may  prove  them  to  be  of  great  importance.  In  the  extremities 
arterial   obstruction    produces   effects   which   are  well  marked.     They 

^  Selected  Obst.  Works,  vol.  i.  p.  523. 
41 


642  THE  PUERPERAL  STATE. 

are  classified  bv  Simpson  under  tlie  I'ollowin^  li<!ads:  1.  Arrixt  of  jtulm 
below  f/ic  .site  of  obstruction.  This  has  been  observed  to  come  on  either 
suddenly  or  gradually,  and  it'  the  oeclusion  be  in  one  of"  the  large 
arterial  trunks  it  is  a  symptom  which  a  careful  examination  will  readily 
enable  us  to  detect.  2.  Increased  force  of  puhation  in  tlie  arteries  above 
the  seat  of  obstruction.  3.  Fall  in  the  temperature  of  the  limb.  This 
is  a  symptom  whieli  is  easily  apprecial)le  by  the  thei'mometer,  and  when 
the  main  artery  of  the  limb  is  oc<?luded  the  coldness  of  tiie  extremity  is 
well  marked.  4.  Lesions  of  motor  and  sensory  functions,  paralysis, 
neuralgia,  etc.  etc.  Loss  of  power  in  the  affected  limb  is  often  a  jiromi- 
nent  symptom,  and  when  it  comes  on  suddenly  and  is  complete  the  main 
artery  will  probably  be  occluded.  It  may  be  diagnosed  from  paralysis 
depending  on  cerebral  or  spinal  causes,  by  the  absence  of  head-symp- 
toms, by  the  history  of  the  attack,  and  by  the  presence  of  other  indica- 
tions of  arterial  obstruction,  such  as  loss  of  pulsation  in  the  artery,  fall 
of  temperature,  etc.  The  sensory  functions  in  these  cases  are  generally 
also  seriously  disturbed,  not  so  much  by  loss  of  sensation  as  by  severe 
pain  and  neuralgia.  Sometimes  the  jMiiu  has  been  excessive,  and  occa- 
sionally it  has  been  the  first  symptom  which  directed  attention  to  the 
state  of  the  limb.  5.  Gangrene  below  or  beyond  the  seat  of  arterial 
obstruction.  Several  interesting  cases  are  recorded  in  which  gangrene 
has  followed  arterial  obstruction.  Generally  speaking,  gangrene  will 
not  follow  occlusion  of  the  main  arterial  trunk  of  an  extremity,  as  the 
collateral  circulation  becomes  soon  sufficiently  developed  to  maintain  its 
vitality.  In  many  of  the  cases  either  thrombi  have  obstructed  the 
channels  of  collateral  circulation  as  well  or  the  veins  of  the  limb  have 
also  been  blocked  up.  AV^hen  such  extensive  obstructions  occur  they 
obviously  cannot  be  embolic,  but  must  depend  on  a  local  thrombosis, 
traceable  to  some  general  blood-dyscrasia  depending  on  the  puerperal 
state. 

Treatment. — Little  can  be  said  as  to  the  treatment  of  such  cases, 
which  must  vary  with  the  gravity  and  nature  of  the  symptoms  in  each. 
Beyond  absolute  rest  (in  the  hope  of  eventual  absorption  of  the  throm- 
bus or  embolus),  generous  diet,  attention  to  the  general  health  of  the 
patient,  and  sedative  applications  to  relieve  the  local  pain,  there  is  little 
in  our  power.  Should  gangrene  of  an  extremity  supervene  in  a  puer- 
peral patient,  the  case  must  necessarily  be  wellnigh  hopeless.  Simp- 
son, however,  records  one  instance  in  which  amputation  wiis  jierformed 
above  the  line  of  demarcation,  the  patient  eventually  recovering. 


OTHER  CAUSES  OF  SUDDEN  DEATH  DURING  LABOR.     043 


CHAPTER  VIII. 

OTHER    CAUSES    OF    SUDDEN    DEATH    DURING    LABOR    AND    THE 
PUERPERAL    STATE. 

A  LARGE  number  of  the  cases  in  which  sudden  death  occui-s  during  or 
after  delivery  find  their  explanation,  as  I  have  already  pointed  out,  in 
thromi)osis  or  embolism  of  the  heart  and  pulmonary  arteries.  Prob- 
al)ly  many  cases  of  the  so-called  idiopathic  a^iphjixia  were,  in  fact,  exam- 
ples of  this  accident,  the  true  nature  of  which  had  been  misunderstood. 
Besides  these  there  are  no  doubt  many  other  conditions  which  may  lead 
to  a  suddenly  fatal  result  in  connection  with  parturition. 

Some  of  these  are  of  an  organic,  others  of  a  functional,  nature. 

Organic  Causes. — Among  the  former  may  be  mentioned  cases  in 
which  the  straining  efforts  of  the  second  stage  of  labor  have  produced 
death  in  patients  suffering  from  some  pre-existent  disease  of  the  heart.) 
Eupture  of  that  organ  has  probably  occurred  from  fatty  degeneration 
of  its  walls.  Dehous'  narrates  an  instance  in  which  the  efforts  of 
labor  caused  the  rupture  of  an  aneurism.  Another  case,  from  interfer- 
ence with  the  action  of  the  heart  in  a  patient  who  had  pericardial  effu- 
sion, is  narrated  by  Ramsbothara.  Dr.  Devilliers  relates  an  instance 
occurring  in  a  young  woman  during  the  second  stage  of  labor.  The 
heart  was  found  to  be  healthy,  but  the  lungs  were  intensely  con- 
gested and  blood  was  extensively  extravasated  all  through  their  texture. 
This  was  probably  caused  by  pulmonary,  pougestion  and  apoplexy  pro- 
duced by  the  severe  straining  efforts.  Many  cases  from  effusion  of 
blood  into  the  brain-substance  or  on  its  surface  are  on  record,  no  doubt 
in  patients  who  from  arterial  degeneration  or  other  causes  were  predis- 
posed to  apoplectic  effusions.  The  so-called  apoplectic  convulsions, 
formerly  described  in  most  works  on  obstetrics  as  a  variety  of  puer- 
j)eral  convulsions,  are  evidently  nothing  more  than  apoplexv  comino-  on 
during  or  after  labor.  As  regards  their  pathology,  they  do  not  seem 
to  differ  from  ordinary  cases  of  apoplexy  In  the  non-pregnant  condition. 
One  example  is  recorded  of  death  which  was  attributed  to  rupture  of  the 
diaphragm  from  excessive  action  in  the  second  stage. 

Functional  Causes. — Among  the  causes  of  death  which  cannot  be 
traced  to  some  distinct  organic  lesion  may  be  classed  cases  of  syncmie, 
shodt,  and  exhaustion.  Many  instances  of  this  kind  are  ree^THed. 
Thus  in  some  women  of  susceptible  uervous  organization  the  severitv 
of  the  suffering  appears  to  bring  on  a  condition  similar  to  that  ])ro- 
duced  by  excessive  shock  or  exhaustion,  which  has  not  unfrequently 
proved  fatal.  Several  examples  of  this  kind  have  been  cited  by 
McClintock.^  It  is  also  not  imlikely  that  sudden  syncope  sometimes 
produces  a  fatal  result  during  or  after  labor.  INIost  cases  of  death  other- 
Avise  inexplicable  used  to  be  referred  to  this  cause;  but  accurate  autop- 
'  Delious,  Sua-  les  Morin  subites.  *  Union  Med.,  1853. 


644  THE  PUERPERAL  STATE. 

sies  were  seldom  made,  and  even  when  they  were — the  important  effects 
of  puhiionary  eoagnla  being  unknown — it  is  more  than  prohal^le  that 
the  true  cause  of  death  was  overlooked.  It  has  l)een  sup})o.sed  that  tlie 
sudden  removal  of  pressure  from  the  veins  of  the  abdomen  by  the 
emptying  of  the  gravid  uterus  after  delivery  may  favor  an  increased 
afflux  of  blood  into  the  lower  parts  of  the  body,  and  thus  tend  to  an 
ana?mic  condition  of  the  brain  and  the  production  of  syncope.  How- 
ever this  may  be,  the  possibility  of  its  occurrence  and  its  manifest 
danger  in  a  recently-delivered  Avoman  are  sufficient  reasons  for  enfor- 
cing the  recumbent  position  after  labor  is  over.  In  some  of  the  cases 
the  syncope  was  evidently  produced  by  the  patient's  suddenly  sitting 
upright. 

Death  from  Air  in  the  Veins.— ^Some  cases  of  sudden  death  imme- 
diately after  labor  seem  to  be  due  to  the  entrance  of  air  into  the  veins. ) 
Six  examples  are  cited  by  McClintock  which  were  prol)ably  due  to  this 
cause.  La  Chapeile  relates  two.  An  interesting  case  is  related  by  M. 
Lionet.^  In  this  the  j3atient  died  five  and  a  half  hours  after  an  easy 
and  natural  labor,  the  chief  symptoms  being  extreme  pallor,  efforts  at 
vomiting,  and  dyspnoea.  Air  was  found  in  the  heart  and  in  the  arach- 
noid veins.  There  can  be  no  question  that  the  uterine  sinuses  after 
delivery  are  nearly  as  well  adapted  as  the  veins  of  the  neck  for  allow- 
ing the  entrance  of  air.  They  are  firmly  attached  to  the  muscular  walls 
of  the  uterus,  so  that  they  gape  open  when  that  organ  is  relaxed,  and 
it  is  easy  to  understand  how  air  might  enter.  Indeed,  in  the  post- 
mortem examination  in  one  of  the  cases  occurring  in  the  practice  of 
Mme.  La  Chapeile  it  is  stated  that  "  the  uterine  sinuses  opened  in  the 
interior  of  the  uterus  by  large  orifices  (one  line  and  a  half  in  diameter), 
through  which  air  could  readily  be  blown  as  far  as  the  iliac  veins,  and 
vice  versa."  The  condition  of  the  uterus  after  delivery  also  enables  the 
air  to  have  ready  access  to  the  mouths  of  the  sinuses,  for  the  alternate 
relaxation  and  contraction  of  the  uterus  occurring  after  the  placenta  is 
expelled  would  tend  to  draw  in  the  air  as  by  a  suction-pump.  Hence 
an  additional  reason  for  insisting  on  firm  contraction  of  the  uterus,  as 
this  will  lessen  the  risk  of  this  accident. 

The  precise  mechanism  of  death  from  air  in  the  veins  has  been  a 
subject  of  dispute  among  pathologists.  By  Bichat^  it  was  referred  to 
anseraia  and  syncope  for  want  of  blood  in  the  vessels  of  the  brain,  which 
are  occupied  by  air.  Nysten  ^  attributed  it  to  distension  of  the  cavities 
of  the  heart  by  rarefied  air,  producing  paralysis  of  its  wall ;  Leroy,  to 
a  stoppage  of  the  pulmonary  circulation  and  consequent  want  of  proper 
blood-supply  to  the  left  heart;  while  Leroy  d'Etoilles  thought  it  might 
depend  on  any  of  these  causes  or  a  combination  of  all  of  them.  These 
and  many  other  hypotheses  on  the  subject  have  been  advanced,  to  all 
which  serious  objection  could  be  raised.  The  most  recent  theory  is 
one  maintained  by  Virchow  and  Oppolzer,^  and  more  recently  by  Feltz, 
which  attributes  the  fatal  results  to  impaction  of  the  air-globules  in  the 

^  Dehous,  op.  cit.,  p.  58.  ^  Rccherches  sur  la  Vie  et  la  Mart,  1853.  ' 

^Nysten,  Recherches  de  Phys.  et  Chim.  Path.,  1811. 

*  Kasuktic  der  EmboUen  ;  Wiener  Med.  Woch.,  1862  ;  Des  Embolics  capillaires,  1868, 
and  op.  cit.,  p.  115. 


PERIPHERAL    VENOUS   TIinOMBOSIS.  645 

lesser  divisions  of  the  pulmonary  arteries,  where  they  form  gaseous 
emboli,  and  eause  death  exa(;tly  in  tiie  same  way  as  when  the  obstruc- 
tion depends  on  a  fibrinous  embolus.  The  symptoms  observed  in  fatal 
cases  closely  corresi)ond  to  those  of  jiulmonary  obstruction,  and  it  is  not 
unlikely  that  some  cases  attributed  to  other  causes  may  really  depend  on 
the  entrance  of  air  through  the  uterine  sinuses.  Such,  for  example,  was 
most  probably  the  exphuiatiou  of  a  case  referred  to  by  Dr.  Graily 
Hewitt  in  a  discussion  at  the  Obstetrical  Society.'  Death  occurred 
shortly  after  the  removal  of  an  adherent  j^lacenta,  during  which,  no 
doubt,  air  could  readily  enter  the  uterine  cavity.  The  symptoms — viz. 
"  severe  pain  in  the  cardiac  region,  distress  as  regards  respiration,  and 
pulselessness" — are  identical  witii  tliose  of  pulmonary  obstruction. 
Dr.  Hewitt  refers  tlie  death  to  shock,  which  certainly  does  not  gen- 
erally produce  such  phenomena. 


CHAPTER   IX. 


PERIPHERAL  VENOUS  THROMBOSIS— (SYN.  CRURAL  PHLEBITIS, 
PHLEGMASIA  DOLENS,  ANASARCA  SEROSA,  (EDEMA  LACTEUM, 
WHITE   LEG,  ETC.). 

Peripheral  Thrombosis. — We  now  come  to  discuss  the  symptoms 
and  pathology  of  the  conditions  associated  with  the  formation  of 
thrombi  iu  the  peripheral  venous  system,  or  rather  in  the  veins  of  the 
lower  extremities,  since  too  little  is  known  of  their  occurrence  iu  other 
parts  to  enable  us  to  say  anything  on  the  subject. 

The  most  important  of  these  is  the  well-known  disease  which  under 
the  n&me  phlec/masia  dolens  has  attracted  much  attention  and  given  rise 
to  numerous  theories  as  to  its  nature  and  pathology.  In  describing  it 
as  a  local  jnanifestation  of  a  general  blood-dyscrasia,  and  not  as  an 
essential  local  disease,  I  am  making  an  assumption  as  to  its  pathology 
that  many  eminent  authorities  would  not  consider  justifiable.  I  have, 
however,  already  stated  some  of  the  reasons  for  so  doing,  and  I  shall 
shortly  hope  to  show  that  this  view  is  not  incompatible  with  the  most 
probable  explanation  of  the  peculiar  state  of  the  atlected  limb. 

Symptoms. — The  first  symptom  which  usually  attracts  attention  is 
severe  pain  in  some  part  of  the  limb  tliat  is  about  to  be  aifected.  The 
character  of  tlic  pain  varies  in  diti'crcnt  cases.  In  some  it  is  extremely 
acute,  aud  is  inost  felt  iu  the  neighborhood  of,  and  along  the  course  of, 
the  chief  venous  trunks.  It  may  begin  in  the  groin  or  hip  and  extend 
downward,  or  it  may  commence  in  the  calf  aud  ]>rocecd  u])ward  towai-d 
the  pelvis.  The  pain  abates  somewhat  after  swelling  of  the  hmb  (which 
generally  begins  within  twenty-four  hours),  but  it  is  always  a  distressing 
1  ObsUt.  Trans.,  1869,  vol.  x.  p.  28. 


646  Till-:  i'ri:i:ri:i:AL  state. 

symptom,  :uul  coiitiiUK-'s  as  lung-  iis  the  :icut<'  st;i<:c  ol'  the  (li.seii.^c  la.sts. 
The  resit lessness,  want  of"  sleep,  and  snt1('i-in<r  Avliich  it  produces  are 
sometimes  excessive.  Coincident  with  the  pain,  and  sometimes  preced- 
ing- it,  more  or  less  iiKilaiyc  is  exj)erienced.  The  patient  may  for  a  day 
or  two  he  restless,  irritable,  and  out  of"  sorts,  withont  any  very  dcfmitci 
cause,  or  the  disi-ase  mav  he  ushered  in  hy  a  distinct  rigor,  (icncrally 
there  is  constitutional  disturl)ance,  varying  with  the  intensity  of  the 
case.  The  pulse  is  rapid  and  weak,  120  or  thereabouts;  the  tem])era- 
ture  elevated  from  101°  to  102°,  with  an  evening  exacerbation.  The 
patient  is  thirsty,  the  tongue  is  glazed  or  white  and  loaded,  the  bowels 
constipated.  In  some  few  cases,  when  the  local  allection  i>  slight,  none 
of  these  constitutional  sym])toms  are  observed. 

Condition  of  the  Affected  Limb. — The  chariicteristie  swelling  rap- 
idly follows  the  commencement  of  the  symptoms.  It  generally  begins 
in  the  groin,  whence_Jt_extejnd§.do>vnward.  It  may  be  limited  tonfTie 
th[gli,  or  the  whole  limb,  even  to  the  feet,  may  be  imjilicated.  More 
rarelv  it  commences  in  the  calf  of  the  leg,  extending  u])ward  to  the 
thigh  and  downward  to  the  feet.  The  affected  parts  have  a  peculiar 
appearance  which  is  pathognomonic  of  the  disease.  They  are  hard, 
tense,  and  brawny,  of  a  shiny  white  color,  and  not  yielding  on  pressure 
except  toward  the  beginning  and  end  of  the  illness.  The  appearances 
presented  are  quite  different  from  those  of  ordinary  axlema.  When 
the  whole  thigh  is  affected  the  limb  is  enormously  increased  in  size. 
Frequently  the  venous  trunks,  especially  the  femoral  and  pojillteal 
veins,  are  felt  obstructed  with  coagula  and  rolling  under  the  finger. 
They  are  painful  when  handled,  and  in  their  course  more  or  less  red- 
ness is  occasionally  observed.  Either  leg  may  be  attacked,  but  the  l^fi 
more  frequently  than  the  right.  There  is  a  marked  tendency  for  the 
disease  to  spread,  and  we  often  find  in  a  case  which  is  progressing 
apparently  well  a  rise  of  temperature  and  an  accession  of  febrile  symj)- 
toms  followed  !)y  the  swelling  of  the  other  limb. 

Progress  of  the  Disease. — After  the  acute  stage  has  lasted  from  a 
week  to  a  fortnight  the  constitutional  disturbance  becomes  less  marked, 
the  pulse  and  temperature  fall,  the  pain  abates,  and  the  sleeplessness 
and  restlessness  are  less.  iThe  swelling  and  tension  of  the  limb  now 
begin  to  diminish  and  absorption  commences.^  This  is  invariably  a  slow 
process.  It  is  always  many  weeks  before  the  effusion  has  disappeared, 
and  it  may  be  many  months.  The  limb  retains  f"or  a  length  of  time 
the  peculiar  icooden  feeling,  as  Dr.  Churchill  terms  it.  Any  im]iru- 
dence,  such  as  jPtoo  early  attempt  at  walking,  may  bring  on  a  relajise 
and  fresh  swelling  of  the  limb.  This  gradual  recovery  is  by  far  the 
most  common  termination  of  the  disease.  In  some  rare  cases  suppura- 
tion may  take  place,  either  in  the  sul)eutaneous  cellular  tissue,  the  lym- 
phatic glands,  or  even  in  the  joints,  and  death  may  result^from  exhaus- 
tion. The  possibility  of  pulmonary  obstruction  and  sudden  death  from 
separation  of  an  embolus  has  already  been  ]iointed  out,  and  the  fact 
tiiat  this  lamentable  occurrence  has  generally  followed  some  undue 
exertion  should  be  borne  in  mind  as  a  guide  in  the  management  of 
our  patient. 

Period  of  Commencement. — The  disease  usually  begins  within  a 


PERIPHFAiAL    VENOUS  TlIliOMIiOSIS.  647 

short  time  aftor  (U'ljvery,  rarely  before  tlie  seeoiid  week.  In  22  cases 
tabulated  by  Dr.  Ivobert  Lee,  7  were  attacrked  between  the  fourth  and 
twelfth  days,  and  14  after  the  second  week.  Sonic  cases  have  Vjceii 
described  as  coniiucncing  even  months  after  delivery.  It  is  question- 
al)le  if  these  can  be  classed  as  puerperal,  for  it  must  not  be  forgotten 
that  phlegmasia  dolens  is  by  no  means  necessarily  a  puer])eral  disease. 
There  are  many  utlu^r  conditions  which  may  give  rise  to  it,  all  of  them, 
liowever,  such  as  [)roduce  a  septic  and  hypei-inosed  state  of  the  blood, 
such  as  malignant  disease,  dysentery,  ])lithisis,  and  the  like.  My  own 
experience  would  lead  me  to  think  that  cases  of  this  kind  are  much 
more  common  than  is  generally  believed.  [I  have  seen  two  attacks, 
several  years  apart  and  in  different  legs,  in  a  male  subject. — Ed.] 

History  and  Pathology. — The  disease  has  long  attracted  the  atten- 
tion of  the  profession.  Passing  over  more  or  less  obscure  notices  by 
Hi|)pocrates,  I)e  Castro,  and  others,  we  find  the  first  clear  account  in 
the  writings  of  Mauriceau,  who  not  only  gave  a  very  accurate  descrip- 
tion of  its  symptoms,  but  made  a  guess  at  its  pathology  which  was  cer- 
tainly more  happy  than  the  speculations  of  his  successors  :  it  is,  he  says, 
caused  ''by  a  reflux  on  the  parts  of  certain  humors  which  ought  to 
have  been  evacuated  by  the  lochia."  Puzos  ascribed  it  to  the  arrest  of 
the  secretion  of  milk  and  its  extravasation  in  the  affected  limb.  This 
theory,  adopted  by  Levret  and  many  subsequent  writers,  took  a  strong 
hold  on  both  professional  and  public  opinion,  and  to  it  we  owe  many  of 
the  names  by  which  the  disease  is  known  to  this  day,  such  as  oedema 
lacteum,  milk  leg,  etc.  In  1784,  Mr.  White  of  ^Manchester  attributed 
it  to  some  morbid  condition  of  the  lymphatic  glands  and  vessels  of  the 
affected  parts;  and  this  or  some  analogous  theory,  such  as  that  of  rup- 
ture of  the  lymphatics  crossing  the  pelvic  brim,  as  maintained  by  Tyre 
of  Gloucester,  or  general  inflammation  of  the  absorbents,  as  held  by 
Dr.  Ferrier,  was  generally  adopted. 

It  was  not  until  the  year  182-3  that  attention  was  drawn  to  the  condi- 
tion of  the  veins.  To  liouillaud  belongs  the  undoubted  merit  of  first 
pointing  out  that /the  veins  of  the  affected  liml)  were  blocked  up  by 
coagula,'^although  the  fact  had  been  previously  observed  by  Dr.  Davis 
of  University  College.  Dr.  Davis  made  dissections  of  the  veins  in  a 
fatal  case,  and  found,  as  Bouillaud  had  done,  that  they  were  filled  with 
coagula,  which  he  assumed  to  be  the  results  of  inflammation  of  their 
coats;  hence  the  name  of"  crural  phlebitis"  which  has  been  extensively 
ado])ted,  instead  of  j^hlegmasia  dolens.  Dr.  Robert  Lee  did  much  to 
favor  this  view,  and,  finding  that  thrombi  were  present  in  the  iliac  and 
uterine,  as  well  as  in  the  femoral  veins,  he  concluded  that  the  phlebitis 
eonuiicnced  in  the  uterine  branches  of  the  hypogastric  veins  and 
extended  downward  to  the  femorals.  Me  ])oint(!d  out  that  jihleg- 
masia  dolens  was  not  limited  to  the  j)uerperal  state,  l)ut  that  when  it 
did  occur  in(le})endently  of  it  other  causes  of  uterine  phlebitis  were 
jM'esent,  such  as  cancer  of  the  os  and  cervix  uteri.  The  inflammatory 
theory  was  ])retty  generally  received,  and  even  now  is  considered  by 
many  to  be  a  sufficient  explanation  of  the  disease.  Indeed,  the  fact 
that  more  or  less  thrombosis  was  always  present  could  not  be  denied; 
and  on  the  supposition  that  thrombosis  coukl  only  be  caused  by  phle- 


C4S  THE  PUERPERAL  STATE. 

bitis,  as  was  long  suppo.sccl  t<»  he  tlio  ca.se,  the  iiiHainniatorv  theory  was 
the  natural  one.  Before  long,  however,  pathologists  pointed  out  that 
thrombosis  was  by  no  moans  necessarily,  or  even  generally,  the  result 
of  inHannnation  of  the  vessels  in  which  the  clot  was  contained,  but  that 
the  intlanimation  was  more  generally  the  result  of  the  coagulum. 

The  late  Dr.  Mackenzie  took  a  j)rominent  part  in  opposing  the  phle- 
bitic  theory.  He  proved  by  numerous  experiments  on  the  lower  ani- 
mals that  inflammation  is  not  .sufficient  of  itself  to  produce  the  exten- 
sive thrombi  which  are  found  to  exi.st,  and  that  inflammation  originat- 
ing in  one  part  of  a  vein  is  not  apt  to  spread  along  its  canal,  as  the 
phlebitic  theory  a.ssumes.  His  conclusion  is  that  the  origin  of  the  dis- 
ease is  rather  to  be  .nought  in  .'^ome  .septic  or  altered  condition  of  the 
blood,  producing  coagulation  in  the  veins.  Dr.  Tyler  Smith  '  jwinted 
out  an  occasional  analogy  between  the  causes  of  pldegmasia  dolens  and 
puerperal  fever,  evidently  recognizing  the  dependence  of  the  former  on 
l3lood-dyscrasia.  "  I  believe,"  he  says,  "  that  contagion  and  infection 
play  a  very  important  part  in  the  })roduction  of  the  disease.  I  look  on 
a  woman  attacked  Avith  ]>hlegmasia  dolens  as  having  made  a  fortunate 
escape  from  the  greater  dangers  of  diffuse  phlebitis  or  puerperal  fever." 
In  illustration  of  this  he  narrates  the  following  instructive  hi.story  :  "A 
short  time  ago  a  friend  of  mine  had  been  in  close  attendance  on  a  patient 
dying  of  erysipelatous  sore  throat  M'ith  sloughing,  and  was  him.self 
affected  with  sore  throat.  Under  these  circumstances  lie  attended, 
within  the  space  of  twenty-four  hours,  three  ladies  in  their  confinements, 
all  of  whom  were  attacked  with  phlegmasia  dolens." 

The  latest  important  contribution  to  the  pathology  of  the  di.sease  is 
contained  in  two  papers  by  Dr.  Tilbuiy  Fox,  published  in  the  second 
volume  of  the  Obstetrical  Transactions.  He  maintained  that  something 
beyond  the  mere  presence  of  coagula  in  the  veins  is  required  to  produce 
the  phenomena  of  the  disease,  although  he  admitted  that  to  be  an 
important,  and  even  an  essential,  part  of  the  pathological  changes  pres- 
ent. The  thrombi  he  believed  to  be  produced  either  by  extrin.sic  or 
intrinsic  causes,  the  former  comprising  all  cases  of  pres.sure  by  tumor 
or  the  like ;  the  latter,  and  the  most  important,  being  divisible  into  the 
heads  of — 

1.  True  inflammatory  changes  in  the  ve.s.sels,  as  seen  in  the  epidemic 
form  of  the  disea:??*;"- — ' 

2.  Sim])le  _thrombus,  produced  by  rapid  absorption  of  morbid  fluid. 

3.  Vims  action  and  thrombus  conjoined,  the  phlegmasia  dolens  itself 
)eing  the  result  of  simple  throml)us,  and  not  produced  by  disea.sed 
[inflamed)  coats  of  vessels ;  the  general  .symptoms  the  result  of  the 
reneral  blood-state. 

He  further  pointed  out  that  the  peculiar  swelling  of  the  limbs  can- 
not be  explained  by  the  mere  presence  of  a-dema,  from  which  it  is 
€.ssentially  dift'erent;  the  white  appearance  of  the  skin,  the  .severe  neur- 
algic pain,  and  the  ])ersistent  nund:)ne.ss  indicating  that  the  whole  of 
the  cutaneous  textures,  the  cutis  vera,  and  even  the  epithelial  layer,  are 
infiltrated  with  fibrinous  deposit.  He  conclndcHl,  therefore,  that  the 
swelling  is  the  result  of  (edema  ^j^ks  something  else,  that  something 

'  Tyler  .Smith,  Manual  of  Obstetrics,  p.  538. 


I'F.rJI'IIERAL   VENOUS  TiiimMnosis.  640 

being  obstruction  of  the  lympliatifs,  by  wliidi  the  absorption  of  offiisi'<l 
serum  i.s  prevented.  Tlie  efficient  cause  which  prfwhices  th(.se  changes 
he  believes  to  be,  in  tlie  majority  of  cuses,  a  septic  action  originating  in 
the  uterus,  producing  a  condition  similar  to  that  in  which  pidegmasia 
dolens  arises  in  the   non-puerperal  state. 

There  is  no  doubt  much  force  in  Dr.  Fox's  arguments,  and  it  mav,  T 
tiiinlv,  be  conceded  that  obstruction  of  the  veins  y^o-  .sr  is  not  sufficient 
to  produce  the  peculiar  appearance  of  the  limb.  It  is,  moreover,  certain 
that  phlebitis  alone  is  also  an  insufficient  explanation,  not  only  of  the 
symptoms,  but  even  of  the  ]>resence  of  throndn  so  extensive  as  those 
that  are  found.  The  view  which  traces  the  disease  solely  to  inflamma- 
tion or  obstruction  of  lymi)hatics  is  purely  theoretical,  has  no  i)asis  of 
facts  to  support  it,  and  finds  now-a-days  no  supjiorters.  The  experi- 
ments of  Mackenzie  and  Lee,  as  well  as  the  vastly  increased  knowledge 
of  the  causes  of  thrombosis  which  the  researches  of  modern  pathologists 
have  given  us,  seem  to  point  strongly  to  the  view  already  stated,  that 
the  disease  can  only  be  explained  by  a  genei'al  blood-dyscrasia  depend- 
ing on  the  puerperal  state.  It  by  no  means  follows  that  we  are  to  con- 
sider Dr.  Fox's  speculations  as  incorrect.  It  is  far  from  improbable 
that  the  lymphatic  vessels  are  implicated  in  the  production  of  tlie  jiecu- 
liar  swelling,  only  we  are  not  as  yet  in  a  position  to  prove  it.  There 
is  no  inherent  improbability  in  the  supposition  that  some  morbid  state 
of  the  l)lood  Avhich  j^roduces  thrombosis  in  the  veins  may  also  give  i-ise 
to  such  an  amount  of  irritation  in  the  lymphatics  as  may  interfere  with 
their  functions,  and  ev^en  obstruct  them  altogether.  The  essential  and 
all-importaut  point  in  the  pathology  of  the  disease,  however,  seems 
undoubtedly  to  be  thrombosis  in  the  veins  ;  and  the  ju'obability  of  there 
being  some  as  yet  undetermined  pathological  changes  in  addition  to  this 
by  no  means  militates  against  the  view  I  have  taken  of  the  intimate 
connection  of  the  disease  with  other  results  of  thrombosis  in  diflcrcnt 
vessels. 

Chang-es  occurring  in  the  Thrombi. — The  changes  which  take 
place  in  the  tlirombi  all  tend  to  their  ultimate  absorption.  These  have 
been  described  by  various  authors  as  leading  to  organization  or  suppu- 
ration. It  is  probable,  however,  that  the  appearances  which  have  led  to 
such  a  supposition  are  fallacious,  and  that  they  are  really  due  to  retro- 
grade metamorphosis  of  the  fibrin,  generally  of  an  amylaceous  or  a  tatty 
character. 

Detachment  of  Emboli. — The  peculiarities  of  a  clot  that  must  f:ivor 
detachment  of  an  emlx^lus  are  that  it  ))resents  such  a  shai>e  as  admits  of  a 
portion  floating  freely  in  the  blood-current,  by  the  force  of  which  it  is 
detached  and  carried  to  its  ultimate  destination.  When  the  accident  has 
occurred  it  is  often  possible  to  recognize  the  j)eripheral  thrombus  from 
which  the  embolus  has  separated  by  the  fact  of  its  terminal  extremity 
presenting  a  fleshy  fractured  end,  instead  of  the  rounded  head  natural  to 
it.  Such  detachment  is  unlikely  to  occur,  even  when  favored  by  the 
shape  of  the  clot,  unless  sufficient  time  have  ela])sed  af\er  its  formation 
to  admit  of  its  softening  and  becoming  brittle.  The  curious  fac-t  I 
have  before  mentioned,  of  true  inier|)eral  embolism  (x-enrring  in  the 
large  majority  of  cases  oidy  after  the  nineteenth  ilay  fnun  tielivery, 


650  TIIK  PUERPERAL  STATE. 

finds    a  ready  explanation   in   this    theory,  wliich   it   remarkably  cor- 
roborates. 

[Although  crural  phlebitis  is  a  rare  secpiel  of  the  Ciesarean  section,  it 
lias  followed  it  and  the  Porro  operation,  both  in  this  city  and  New 
York,  in  two  cases  of  each,  three  of  which  were  seen  by  the  writer.  It 
is  most  likely  to  occur  in  antemic  subjects  or  where  there  has  been  a 
secondary  destruction  of  tissue  from  injurious  j)ressure  in  a  long  labor. 
In  my  experience  it  is  most  likely  to  show  itself  about  the  middle  of 
the  third  week.  The  disease  may  occur  in  delicate  men  and  in  unmar- 
ried Avomen. — Ed.] 

Treatment. — On  the  supposition  tha.t  phlegmasia  dolens  was  the 
result  of  inflammation  of  the  veins  of  the  affected  limb  an  antiphlo- 
gistic course  (^f  treatment  was  naturally  adopted.  Accordingly,  most 
writers  on  the  subject  recommended  depletion,  generally  by  the  applica- 
tion of  leeches  along  the  course  of  the  affected  vessels.  A\'^e  are  told 
that  if  the  pain  continue  the  leeches  should  be  applied  a  second  or  even 
a  third  time.  If  we  admit  the  septic  origin  of  the  disease,  we  mnst,  I 
think,  see  the  impropriety  of  such  a  practice.  The  fact  that  it  occurs 
in  a  large  majority  of  cases  in  patients  of  a  weakly  and  debilitated  con- 
stitution, often  in  women  who  have  suffered  from  hemorrhage,  is  a 
further  reason  for  not  adopting  this  routine  custom.  If  local  deple- 
tion be  employed,  it  should  be  strictly  limited  to  cases  in  which 
there  is  much  tenderness  and  redness  across  the  course  of  the  veins,  and 
then  only  in  patients  of  plethoric  habits  and  strong  constitution.  Cases 
of  this  kind  will  form  a  very  small  minority  of  those  coming  under 
our  observation. 

What  has  been  said  of  the  pathology  of  the  affection  tends  to  the 
conclusion  that  active  treatment  of  any  kind  in  the  hope  of  curing  the 
disease  is  likely  to  be  useless.  (Our  chief  reliance  must  be  onetime  and 
perfect  rest  in  order  to  admit  of  the  thrombi  and  the  secondary  effusion 
being^sorbed,  while  we  relieve  the  pain  and  other  prominent  symptoms 
and  support  the  strength  and  improve  the  constitution  of  the  patient. 

n?he  constant  application  of  heat  and  moisture  to  the  affected  limb 
will  do  much  to  lessen  the  tension  and  pain.  J  Wrapping  the  entire 
limb  in  linseed-meal  poultices,  frequently  changed,  is  one  of  the  best 
means  of  meeting  this  indication.  If,  as  is  sometimes  the  case,  the 
Aveight  of  the  poultices  be  too  great  to  be  readily  borne,  we  may  substi- 
tute Avarm  flannel  stupes  covered  with  oiled  silk.  Lpgil  anodyne  appli- 
cations afford  nuich  relief,  and  may  be  advantageously  used  along  with 
the  poultices  and  stupes,  either  by  sprinkling  their  surface  freely  with 
laudanum  or  chloroform  and  belladonna  liniment  or  by  soaking  the 
flannels  in  poppy-head  fomentations.  It  is  needless  to  say  that  the 
most  absolute  rest  in  l)cd  should  be  enjoined  even  in  slight  cases,  and 
that  the  limb  should  be  effectually  guarded  from  undue  pressure  by  a 
cradle  or  some  similar  contrivance.  Locajcounter-irritation  has  been 
strongly  recommended,  and  frequent  blisters  liave  been  considered  by 
some  to  be  almost  specific.  I  shoidd  myself  hesitate  to  use  blisters,  as 
they  would  certainly  not  be  soothing  applications,  and  one  hardly  sees 
how  they  can  be  of  much  service  in  hastening  the  absorption  of  the 
effusion. 


PERIPHERAL    VENOUS  THROMBOSIS.  i\')\ 

During  the  acute  stage  of  the  disease  the  con.stitiitioiial  treatment 
must  he  rcguhited  hy  the  CMjudition  of  tlie  patient.  Light  hut  nutri- 
tious diet  nuist  he  achuinistered  in  ahun(huH'o,  such  as  milk",  hccf-tca, 
and  soups.  Should  tlicre  he  nuich  dchility,  stinudants  in  niodci-ation 
may  pr<jve  of  service.  Witii  regard  to  mecHcincs  we  shall  pi'ohahlv 
find  henefit  from  such  as  are  calcidatcd  to  improve  the  condition  of  the 
blood  and  the  general  health  of  the  ])atient.  Chlorate  of  potash,  with 
diluted  hydrochloric  acid,  quinine,  either  alone  or  in  combination  w  ilh 
sesquicarbonate  of  ammonia,  the  tincture  of  the  ])erchloride  of  iron, — 
are  the  drugs  that  are  most  likely  to  prove  of  service.  Alkalies  and 
other  medicines  which  have  been  recommended  in  the  hope  of  hasten- 
ing the  absorption  of  coagula  must  be  considered  as  altogether  useless. 
Pain  must  be  relieved  and  sleep  procured  by  the  judicious  use  of  ano- 
dynes, such  as  Dover's  powder,  the  subcutaneous  injection  of  morphia, 
or  chloral.  Generally  no  form  answers  so  well  as  the  hypodermic 
injection  of  morphia. 

When  the  acute  symptoms  have  abated  and  the  temperature  has  fallen, 
the  poultices  and  stupes  maybe  discontinued  and  the  limbs  swathed  in 
a  flannel  roller  from  the  toes  upward.  The  equable  pi-essure  and  sup- 
port thus  afforded  materially  aid  the  absorption  of  the  eTPusion  and  tend 
to  diminish  the  size  of  the  limb.  At  a  still  later  stage  very  gentle 
inunctions  of  weak  iodine  ointment  may  be  used  with  advantage  once  a 
day  before  the  roller  is  applied.  Sharajipoing  and  friction  of  the  limb, 
generally  recommended  for  the  purpose  of  hastening  absor})tion,  should 
be  carefully  avoided,  on  account  of  the  possible  risk  of  detaching  a 
portion  of  the  coagulum  and  producing  embolism.  This  is  no  merely 
imaginary  danger,  as  the  following  fact  narrated  by  Trousseau  proves : 
"A  phlegmasia  alba  dolens  had  appeared  on  the  left  side  in  a  young 
woman  suffering  from  periuterine  phlegmon.  The  pain  having  ceased, 
a  thickened  venous  trunk  was  felt  on  the  upper  and  internal  part  of 
the  thigh.  Rather  strong  pressure  was  being  made,  when  ]M.  Demar- 
quay  felt  something  yield  under  his  fingers.  A  few  minutes  afterward 
the  patient  was  attacked  with  dreadful  palpitation,  tumultuous  cardiac 
action,  and  extreme  pallor,  and  death  was  believed  to  be  imminent. 
After  some  hours,  however,  the  oppression  ceased  and  the  jiatient  event- 
ually recovered.  A  slightly  attached  coagulum  must  have  become 
separated  and  conveyed  to  the  heart  or  pulmonary  artery."'  Warm 
douches  of  water — of  salt  water  if  it  can  be  obtained — may  be  advan- 
tageously used  in  the  later  stages  of  the  disease,  and  they  may  be 
applied  night  and  morning,  the  limb  being  bandaged  in  the  interval. 
The  occasional  use  of  the  continuous  current  is  said  to  ])romote  absorp- 
tion, and  would  seem  likely  to  be  a  serviceable  remedy. 

(When  the  patient  is  well  enough  to  be  moved  a  change  of  air  to  the 
seaside  will  be  of  value. '  Great  caution,  however,  should  be  recom- 
mended in  using  the  limb,  and  it  is  far  better  not  to  run  the  risk  of 
a  relapse  by  any  undue  haste  in  this  respect.  It  is  "svell  to  warn  the 
patient  and  her  friends  that  a  considerable  time  nmst  of  necessity 
elapse  before  the  local  signs  of  the  disease  have  completely  disap- 
peared. 

^Trousseau,  C/inique  dc  I' Hold  Dicu,  in  Gaz.  dcs  Hop.,  1800,  p.  577. 


G52  THE  PUERPERAL  STATE. 


CHAPTER    X. 

PELVIC    CELLULITIS  AND    PELVIC   PERITONITIS. 

These  Diseases  have  been  Recog-nized  from  the  Earliest  Times. 
— From  tlie  earliest  times  tlie  occurrence  after  parturition  of  severe 
forms  of  inflammatory  disease  in  and  about  the  pelvis,  frequently 
ending  in  suppuration,  has  been  well  known.  It  is  only  of  late  years, 
however,  that  these  diseases  have  been  made  the  subject  of  accurate 
clinical  and  pathological  investigation,  and  that  their  true  nature  has 
begun  to  be  understood.  Nor  is  our  knowledge  of  them  as  yet  by  any 
means  complete.  They  merit  careful  study  on  the  part  of  the  accou- 
cheur, for  they  give  rise  to  some  of  the  most  severe  and  protracted 
illnesses  from  which  puerperal  patients  suffer.  They  are  often  obscure 
in  their  origin  and  apt  to  be  overlooked,  and  they  not  rarely  leave 
behind  them  lasting  mischief. 

These  diseases  are  not  limited  to  the  puerperal  state.  On  the  con- 
trary, many  of  the  severest  cases  arise  from  causes  altogether  uncon- 
nected with  childbearing.  These  will  not  be  now  considered,  and  this 
chapter  deals  solely  with  such  forms  as  may  be  directly  traced  to  child- 
birth. 

]\Iodern  researches  have  demonstrated  that  there  are  two  distinct 
varieties  of  inflammatory  disease  met  with  after  labor  which  diifer 
materially  from  each  other  in  many  respects.  In  one  of  these  the 
inflammation  affects  chiefly  the  connective  tissue  surrounding  the 
generative  organs  contained  within  the  pelvis,  or  extends  up  from 
beneath  the  peritoneum  and  into  the  iliac  fossee.  In  the  other  it 
attacks  that  portion  of  the  peritoneum  M'hich  covers  the  pelvic  viscera, 
and  is  limited  to  it. 

Variety  of  Nomenclature. — So  much  is  admitted  by  all  M-riters, 
but  great  obscurity  in  description,  and  consequent  difficulty  in  under- 
standing satisfactorily  the  nature  of  these  affections,  have  resulted  from 
the  variety  of  nomenclature  M'hich  different  authors  have  adopted. 

Thus  the  former  disease  has  been  variously  described  as  pelvic  cellu- 
litis, periuterine  phlegmon,  parametritis,  or  pelvic  abscess,  while  the 
latter  is  not  unfrequently  called  perimetritis,  as  contradistinguished 
from  parametritis.  The  use  of  the  prefix  ;)or«  or  jyeri  to  distinguish 
cellular  or  peritoneal  variety  of  inflammation,  originally  suggested  by 
Virchow,  has  been  pretty  generally  adopted  in  Germany,  and  has  been 
strongly  advocated  in  Great  Britain  by  INIatthews  Duncan.  It  has  never, 
however,  found  much  favor  with  English  writers,  and  the  similarity  of 
the  two  names  is  so  great  as  to  lead  to  confusion.  I  have,  therefore, 
selected  the  terras  "  pelvic  peritonitis  "  and  "  pelvic  cellulitis,"  as  con- 
veying in  themselyes  a  fairly  accui'ate  notion  of  the  tissues  mainly 
involved. 


PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS.  653 

Importance  of  Distinguishing-  the  Two  Classes  of  Cases. — The 
important  fact  to  remember  is  that  there  exist  two  distinct  varieties  of 
inflammatory  disease  presenting  many  similarities  in  their  course,  symp- 
toms, and  results,  often  occurring  simultaneously,  but  in  the  main  dis- 
tinct in  their  pathology  and  capable  of  being  differentiated.  Thomas 
compares  them — and,  as  serving  to  fix  the  facts  on  the  memory,  the 
illustration  is  a  good  one — to  pleurisy  and  pneumonia.  "  Like  them," 
he  says,  "  they  are  separate  and  distinct,  like  them  affect  different  kinds 
of  structure,  and  like  them  they  generally  complicate  each  other."  It 
might  therefore  be  advisable,  as  most  writers  on  the  disease  occurring 
in  the  nou-puerperal  state  have  done,  to  treat  of  them  in  two  separate 
chapters.  There  is,  however,  more  difficulty  in  distinguishing  them 
as  puerperal  than  as  uon-puer])eral  affections,  for  which  reason,  as  M'ell 
as  for  the  sake  of  brevity,  I  think  it  better  to  consider  them  together, 
pointing  out  as  I  proceed  the  distinctive  peculiarities  of  each. 

Seat  of  Disease. — When  attention  was  first  directed  to  this  class  of 
diseases  the  pelvic  celluluar  tissue  was  believed  to  be  the  only  structure 
affected.  This  was  the  view  maintained  by  Nonat,  Simpson,  and  many 
modern  writers.  Attention  was  first  prominently  directed  to  the  import- 
ance of  localized  inflammation  of  the  peritoneum,  and  to  the  fact  that 
many  of  the  supposed  cases  of  cellulitis  were  really  peritonitic,  by  Ber- 
nutz.  There  can  be  no  doubt  that  he  here  made  an  enormous  step  in 
advance.  Like  many  authors,  however,  he  rode  his  hobby  a  little  too 
hard,  and  he  erred  in  denying  the  occurrence  of  cellulitis  in  many  cases 
in  which  it  undoubtedly  exists. 

Etiology. — The  great  influence  of  childbirth  in  producing  these 
diseases  has  long  been  fully  recognized.  Courty  estimates  that  about 
two-thirds  of  all  the  cases  met  with  occur  in  connection  with  delivery 
or  abortion,  and  Duncan  found  that  out  of  40  carefully  observed  cases 
25  were  associated  with  the  puerperal  state. 

It  is  pretty  generally  admitted  by  most  modern  writers  that  both 
varieties  of  the  disease  are  produced  by  the  extension  of  inflammation 
from  either  the  uterus,  the  Fallopian  tubes,  or  the  ovaries.  This  point 
has  been  especially  insisted  on  by  Duncan,  who  maintains  that  the  dis- 
ease is  never  idiopathic,  and  is  ''  invariably  secondary  either  to  mechan- 
ical injury,  or  to  the  extension  of  inflammation  of  some  of  the  pelvic 
viscera,  or  to  the  irritation  of  the  noxious  discharges  through  or  from 
the  tubes  or  ovaries." 

Their  intimate  connection  with  puerperal  septicaemia  is  also  a  promi- 
nent fact  in  the  natural  history  of  the  diseases.  Barker  mentions  a 
curious  observation  illustrative  of  this,  that  when  puerperal  fever  is 
endemic  in  the  Bellevu-e  Hospital  in  New  York,  cases  of  pelvic  peri- 
tonitis and  cellulitis  are  also  invariably  met  with.  Olshauseu  has  also 
remarked  that  in  the  Lying-in  Hospital  at  Halle  during  the  autumn 
vacation,  when  the  patients  are  not  attended  by  practitioners,  and 
when,  therefore,  the  chance  of  septic  infection  being  conveyed  to  them 
is  less,  these  inflammations  are  almost  always  absent.  As  inflammations 
of  the  lining  membrane  of  the  uterus,  the  vaginal  mucous  membrane, 
and  the  pelvic  connective  tissue  are  of  very  constant  occurrence  as 
local  phenomena  of  septic  absorption,  the  connection  between  the  two 


654  THE  PUERPERAL  STATE. 

cla.sses  of"  cases  is  readily  susc'cj)tibk'  ctf  explanation.  Sehroetler,  indeed, 
goes  further  and  includes  his  descrij)ti()n  ot"  these  diseases  under  the  head 
of  "  puerj)ei-al  lever."  They  do  not,  however,  necessarily  depend  njxju 
it;  for,  althoujih  it  nnist  be  admitted  that  cases  of  this  kind  form  a  lai-^e 
proportion  of  those  met  with,  othei's  un<|uestionahly  occur  which  caiuiot 
be  traced  to  such  sources,  but  are  the  direct  result  of  causes  altotrether 
uncouueeted  with  the  inHammatiou  attendino;  on  septic  absorption,  such 
as  undue  exertion  shortly  after  delivery  or  premature  coition.  Mechani- 
cal causes  may  beyond  doubt  excite  tlie  disease  in  a  woman  ))redisposed 
bv  the  pueri)eral  process,  but  they  cannot  fairly  be  included  under  tlie 
head  of  puerperal   fever. 

Seat  of  the  Inflammation  in  Pelvic  Cellulitis. — Abundance  of 
areolar  tissue  exists  iu  connection  with  the  ])elvic  viscera,  which  may 
be  the  seat  of  cellulitis.  It  forms  a  loose  padding  between  the  organs 
contained  iu  the  pelvis  proper,  surrounds  the  vagina,  the  rectum,  and 
the  bladder,  and  is  found  in  cousiderable  quantity  between  the  folds 
of  the  broad  ligaments.  From  these  parts  it  extends  uj)ward  to  the 
iliac  fosste  and  the  inner  surface  of  the  abdominal  parietes.  In  any 
of  these  positions  it  may  be  the  seat  of  the  kind  of  inflammation  we 
are  discussing.  The  essential  character  of  the  inflammation  is  similar 
to  that  which  accompanies  areolar  inflammation  in  other  parts  of  the 
bodv.  There  is  first  an  acute  inflammatory  oedema,  followed  l)y  the 
infiltration  of  the  areolae  of  the  connective  tissue  with  exudation,  and 
the  consequent  formation  of  appreciable  swellings.  These  may  form 
in  any  part  of  the  pelvis.  Thus  "we  may  meet  with  them — and  this 
is  a  very  common  situation — between  the  folds  of  the  broad  ligaments, 
forming  distinct  hard  tumors  connected  with  the  uterus  and  extending 
to  the  pelvic  walls,  their  rounded  outlines  being  readily  made  out  by 
bimanual  examination.  If  the  cellulitis  be  limited  in  extent,  such  a 
swelling  may  exist  on  one  side  of  the  uterus  only,  forming  a  rounded 
mass  of  varying  size  and  apparently  attached  to  it.  At  other  times  the 
exudation  is  more  extensive,  and  may  completely  or  partially  surround 
the  uterus,  extending  to  the  cellular  tissue  between  the  vagina  and  rec- 
tum or  between  the  uterus  and  the  bladder.  In  such  cases  the  uterus 
is  imbedded  and  firmly  fixed  in  dense,  hard  exudation.  At  other  times 
the  inflammation  chiefly  affects  the  cellular  tissue  covering  the  nuiscles 
lining  the  iliac  fossae.  There  it  forms  a  mass  easily  made  out  by  palpa- 
tion, but  on  vaginal  examination  little  or  no  trace  of  the  exudation  oan 
be  felt,  or  only  a  sense  of  thickness  at  the  roof  of  the  vagina  on  the 
same  side  as  the  swelling. 

Seat  of  the  Inflammation  in  Pelvic  Peritonitis. — In  ]ielvic  peri- 
tonitis the  inflammation  is  limited  to  that  portion  of  the  peritoneum 
Avhich  invests  the  jielvic  viscera.  Its  extent  necessarily  varies  with  the 
intensity  and  duration  of  the  attack.  In  some  cases  there  may  be  little 
more  than  irritation,  while  more  often  it  runs  on  to  exudation  of  plastic 
material.  The  result  is  generally  complete  fixation  of  the  uterus  and 
hardening  and  swelling  in  the  roof  of  the  vagina,  and  the  lymj)h  poured 
out  may  mat  together  the  surrounding  viscera,  so  as  to  form  swellings 
difficult,  in  some  cases,  to  differentiate  from  those  resulting  from  cellu- 
litis.    On  post-mortem  examination  the  pelvic  viscera  are  found  exten- 


PELVIC  CELLULITIS  AND  PELVIC  PERirONITIS.  655 

sivoly  adlicrcnt,  and  tlic  agglutination  may  involve  tlic  cuils  of  the 
intestine  in  the  vicinity  so  as  sometimes  to  form  tumors  of"  consider- 
able size. 

Relative  Frequency  of  the  Two  Forms  of  Disease. — Tiie  relative 
frequency  of  these  two  forms  of  inflammation  as  j)ueri)eral  affections  is 
not  easy  to  ascertain.  In  the  non-puer]ieral  state  the  peritonitic  variety 
is  nnicii  the  more  common,  but  in  the  puerperal  state  they  very  gener- 
ally complicate  each  other,  and  it  is  rare  for  cellulitis  to  exist  to  any 
great  extent  without  more  or  less  peritonitis. 

Symptomatology. — The  earliest  symptom  is  pain  in  the  lower  ])art 
of  the  abdomen,  which  is  generally  preceded  by  rigor  or  chilliness.  The 
amount  of  pain  varies  much.  Sometimes  it  is  comparatively  slight,  and 
it  is  by  no  means  rare  to  meet  with  ])atieuts  the  subjects  of  very  con- 
siderable exudations  who  suffer  little  more  than  a  certain  sense  of 
weight  and  discomfort  at  the  lower  part  of  the  abdomen.  On  the 
other  hand,  the  suifering  may  be  excessive,  and  is  characterized  by 
paroxysmal  exacerbations,  the  patient  being  comparatively  free  from 
pain  for  several  successive  hours,  and  then  having  attacks  of  the  most 
acute  agony.  Schroeder  says  that  pain  is  always  a  symptom  of  perito- 
nitis, and  that  it  does  not  exist  in  uncomplicated  cellulitis.  The  swellings 
of  cellulitis  are  certainly  sometimes  remarkably  free  from  tenderness,  and 
I  have  often  seen  masses  of  exudation  in  the  iliac  fossae  which  could 
bear  even  rough  handling.  On  the  other  hand,  although  this  is  cer- 
tainly more  often  met  with  in  non-puerperal  cases,  the  tenderness  over 
the  abdomen  is  sometimes  excessive,  the  patient  shrinking  from  the 
slightest  touch.  The  pulse  is  raised,  generally  from  100  to  120,  and 
the  thermometer  shows  the  presence  of  pyrexia.  During  the  entire 
course  of  the  disease  both  these  symptoms  continue.  The  temperature 
is  often  very  high,  but  more  frequently  it  varies  from  100°  to  104°, 
and  it  generally  shows  more  or  less  marked  remissions.  In  some  cases 
the  temperature  is  said  not  to  be  elevated  at  all,  or  even  to  be  subnor- 
mal, but  this  is  certainly  quite  exceptional.  Other  signs  of  local  and 
general  irritation  often  exist.  Among  them,  and  most  distinctly  in 
cases  of  peritonitis,  are  nausea  aud  vomiting,  and  an  anxious,  pinched 
expression  of  the  countenance,  while  the  local  mischief  often  causes 
distressing  dysuria  and  tenesmus.  The  latter  is  especially  apt  to  occur 
when  there  is  exudation  between  the  rectum  and  vagina  which  presses 
on  the  bowel.  The  passage  of  feces,  unless  in  a  very  liquid  form,  may 
then  cause  intolerable  suffering. 

Such  symptoms  may  show  themselves  within  a  few  days  after  deliverv, 
and  then  they  can  barely  fail  to  attract  attention.  On  the  other  hand, 
they  may  not  commence  for  some  weeks  after  labor,  and  then  thev  are 
often  insidious  in  their  onset  and  apt  to  be  overlooker!.  It  is  far  from 
rare  to  meet  with  cases  six  weeks  or  more  after  confinement  in  which 
the  patient  complains  of  little  beyond  a  feeling  of  malaise  and  discom- 
fort, and  in  which,  on  investigation,  a  considerable  amount  of  exudation 
is  detected  which  had  previously  entirely  escaped  observation. 

Results  of  Physical  Examination. — On  introducing  the  finijer  into 
the  vagina  it  will  be  found  to  l)e  hot  and  swollen,  in  some  cases  dis- 
tinctly (edematous,  and  on  reaching  the  vaginal  cul-ile-sac  the  existence 


6o6  THE  PUERPERAL  STATE. 

of  exiulatiou  may  generally  be  made  out.  The  amount  of  thi.s  varies 
mueii.  Sometimes,  especially  in  the  early  stage  of  the  disease,  there  is 
little  more  than  a  diffuse  sense  of  thickness  and  induration  at  either 
side  of,  or  behind,  the  uterus.  More  generally,  careful  bimanual  exam- 
ination enables  us  to  detect  a  distinct  hardening  and  swelling,  }X)Ssibly 
a  tumor  of  considerable  size,  ^vhich  may  apparently  be  attached  to  the 
sides  of  the  uterus  and  rise  above  the  pelvic  brim,  or  may  extend  quite 
to  the  pelvic  walls.  The  examination  should  be  very  carefully  and 
systematically  conducted  with  both  hands,  so  as  to  explore  the  whole 
contour  of  the  uterus  before,  behind,  and  on  either  side,  as  well  as  the 
iliac  fossae;  otherwise  a  considerable  exudation  might  readily  escape 
detection.  ^M^en  the  exudation  is  at  all  great,  more  or  less  fixity  of 
the  uterus  is  sure  to  exist,  and  is  a  veiy  characteristic  symptom.  The 
womb,  instead  of  being  freely  movable  by  the  examining  finger,  is 
firmly  fixed  by  the  surrounding  exudation,  and  in  severe  forms  of  the 
disease  is  quite  encased  in  it.  More  or  less  displacement  of  the  organ 
is  also  of  common  occurrence.  If  the  SM-elling  be  limited  to  one  side 
of  the  pelvis  or  to  Douglas'  space,  the  uterus  is  displaced  in  the  oppo- 
site direction,  so  that  it  is  no  longer  in  its  usual  central  position. 

The  differential  diagnosis  of  pelvic  cellulitis  and  pelvic  peritonitis 
cannot  always  be  made,  and  indeed  in  many  cases  it  is  impossible,  since 
both  varieties  of  disease  coexist.  The  elements  of  differentiation  gen- 
erally insisted  on  are,  the  greater  general  disturbance,  nausea,  etc.  in 
pelvic  peritonitis,  with  an  earlier  commencement  of  the  symptoms  after 
labor.  The  swellings  of  pelvic  peritonitis  are  also  more  tender,  with 
less  clearly  defined  outline  than  those  of  cellulitis.  When  the  cellulitis 
involves  the  iliac  fossa,  the  diagnosis  is  of  course  easy,  and  then  a  con- 
tinuous retraction  of  the  thigh  on  the  affected  side  (an  involuntary  posi- 
tion assumed  with  the  view  of  keeping  the  muscles  lining  the  iliac  fossa 
at  rest)  is  often  observed.  When  the  inflammation  is  chiefly  limited  to 
the  cavity  of  the  pelvis,  the  distinction  between  the  two  classes  of  cases 
cannot  be  made  with  any  degree  of  certainty. 

Terminations. — Both  forms  of  disease  may  end  either  in  resolution 
or  in  suppuration.  In  the  former  case,  after  the  acute  symptoms  have 
existed  for  a  variable  time — it  may  be  for  a  few  days  only,  it  may  be  for 
many  weeks — their  severity  abates,  the  swellings  become  less  tender  and 
commence  to  contract,  become  harder,  and  are  gradually  absorbed,  until 
at  last  the  fixity  of  the  uterus  disappeai-s  and  it  again  resumes  its  central 
position  in  the  pelvic  cavity.  This  process  is  often  very  gradual.  It  is 
by  no  means  rare  to  find  a  patient,  even  some  months  after  the  attack, 
when  all  acute  symptoms  have  long  disappeared,  who  is  even  able  to 
move  about  without  inconvenience,  in  whom  the  uterus  is  still  immov- 
ably fixed  in  a  mass  of  deposit  or  is  at  least  adherent  in  some  part  of 
its  contotir.  More  or  less  permanent  adhesions  are  of  common  occur- 
rence, and  give  rise  to  symptoms  of  considerable  obscurity,  which  are 
often  not  traced  to  their  proper  source. 

Symptoms  of  Suppuration. — When  the  inflammation  is  about  to 
terminate  in  suppuration  the  pyrexia!  symptoms  continue,  and  event- 
ually well-marked  hectic  is  developed,  the  temperatiu'e  generally  show- 
ing a  distinct  exacerbation  at  night.     At  the  same  time  rigors,  loss  of 


PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS.  657 

appetite,  a  peculiar  yellowish  discoloration  of  tlie  face,  and  other  signs 
of  su])|)nrati()n  show  tlieniselves.  The  relative  frequency  of  this 
termination  is  variously  estimated  by  authors.  Duncan  quotes  Simj)- 
sou  as  calculating  it  as  occurring  in  half  the  cases  of  pelvic  cellulitis, 
but  states  his  own  belief  that  it  is  much  more  frequent.  West 
observed  it  in  23  out  of  4-3  cases  following  delivery  or  abortion,  and 
McClintock  in  37  out  of  70.  Schroeder  says  that  he  has  only  once  seen 
snp})uration  in  92  cases  of  distinctly  demonstrable  exudation — a  result 
which  is  certainly  totally  opposed  to  common  ex])erience.  Barker  also 
states  that  in  his  experience  suppuration  in  either  pelvic  peritonitis  or 
cellulitis  "is  very  rare,  except  when  they  are  associated  with  pyaemia 
or  puerperal  fever."  It  is  certain  that  suppuration  is  more  likely  to 
occur  in  pelvic  cellulitis  than  in  pelvic  peritonitis,  but  it  unquestion- 
ably occurs,  in  Great  Britain  at  least,  much  more  frequently  than  the 
statements  of  either  of  these  authors  would  lead  us  to  suppose. 

Channels  throug-h  which  Pus  may  Escape. — The  pus  may  find 
an  exit  through  various  channels.  In  pelvic  cellulitis,  more  especially 
when  the  areolar  tissue  of  the  iliac  fossa  is  implicated,  the  most  com- 
mon site  of  exit  is  through  the  abdominal  wall.  It  may,  however,  open 
at  other  positions,  and  the  pus  may  find  its  way  through  the  cellular 
tissue  and  point  at  the  side  of  the  anus  or  in  the  vagina,  or  it  may  take 
even  a  more  tortuous  course  and  reach  the  inner  surface  of  the  thigh. 
Pelvic  abscesses  not  uncommonly  open  into  the  rectum  or  bladder,  caus- 
ing very  considerable  distress  from  tenesmus  or  dysuria.  According  to 
Hervieux,  it  is  chiefly  the  peritoneal  varieties  which  open  in  this  way. 
Not  unfrequently  more  than  one  opening  is  formed ;  and  when  the  pus 
has  burrowed  for  any  distance  long  fistulous  tracts  result  which  secrete 
pus  for  a  length  of  time  and  are  very  slow  to  heal.  Rupture  of  an 
abscess  into  the  peritoneal  cavity,  especially  of  a  peritonitic  abscess,  is 
a  possible  (but  fortunately  a  very  rare)  termination,  and  will  generally 
prove  fatal  by  producing  general  peritonitis.  In  one  case  which  I  have 
recorded  in  the  fifteenth  volume  of  the  Obstetrical  Transactions  suppu- 
ration was  followed  by  extensive  necrosis  of  the  pelvic  bones.  Two 
similar  cases  are  related  by  Trousseau  in  his  Clinical  3fedicine,  but  I 
have  not  been  able  to  meet  with  any  other  examples  of  this  rare  com- 
plication, which  was  probably  rather  the  result  of  some  obscure  septi- 
cemic condition  than  of  extension  of  the  inflammation. 

Prognosis. — The  prognosis  is  favorable  as  regards  ultimate  recoverv, 
but  there  is  great  risk  of  a  protracted  illness  which  may  seriously  impair 
the  health  of  the  j^atient,  especially  if  suppuration  result.  Hence  it  is 
necessary  to  be  guarded  in  an  expression  of  opinion  as  to  the  conse- 
quences of  the  disease.  Secondary  mischief  is  also  far  from  unlikely 
to  follow  from  the  physical  changes  produced  by  the  exudation,  such  as 
permanent  adhesions  or  midpositions  of  the  uterus  or  organic  altei'ations 
in  the  ovaries  or  Fallopian  tubes. 

Treatment. — In  the  treatment  of  both  forms  of  disease  the  import- 
ant points  to  bear  in  mind  are  the  relief  of  pain  and  the  necessity  of 
absolute  rest ;  and  to  these  objects  all  our  measures  must  be  subordinate, 
since  it  is  quite  hopeless  to  attempt  to  cut  short  the  inflammation  by  any 
active  medication. 

42 


658  THE  PUERPERAL  STATE. 

II'  the  disease  be  reeoiiiii/ed  at  a  very  early  stage,  the  loeal  ahstrar- 
ti(Hi  nf  blood  by  the  applieation  of  a  lew  leeches  to  the  groin  or  to  the 
hemorrhoidal  veins  may  give  relief",  1)nt  tlie  inflnence  of  this  remedy 
has  been  greatly  e.xaggei-ated,  and  wiien  the  disease  is  of  any  standing 
it  is  (jnite  useless.  Leeehes  to  the  uterus,  often  recommended,  are,  J 
believe,  likely  to  do  more  harm  than  good  (unless  in  very  skilful 
hands)  from  the  irritation  produced  by  passing  the  s[)eculum.  C)j)iates 
in  large  doses  may  be  said  to  be  our  sheet-anchor  in  treatment  when- 
ever the  pain  is  at  all  severe,  either  by  the  mouth,  in  the  form  of  mor- 
phia sup])ositories,  oi'  injected  sul)cutaneously.  In  the  not  uncommon 
cases  in  which  ])ain  comes  on  severely  in  j)aroxysms  the  opiates  should 
be  administered  in  sufiicient  quantity  to  lull  the  j)ain  ;  and  it  is  a  good 
plan  to  give  the  nurse  a  supply  of  morphia  suj)positories  (wliich  often 
act  better  than  any  other  form  of  administering  the  drug),  with  direc- 
tions to  use  them  immediately  the  pain  threatens  to  come  on.  When 
there  is  much  jjyrexia  large  doses  of  quinine  may  be  given  with  great 
advantage  along  with  the  opiates.  The  state  of  the  l)owels  recpiires 
careful  attention.  The  opiates  are  apt  to  produce  constipation,  and  the 
passage  of  hardened  feces  causes  much  suffering.  Hence  it  is  desirable 
to  keep  the  bowels  freely  open.  ]S^othing  answers  this  purpose  so  well 
as  small  doses  of  castor  oil,  such  as  half  a  teaspoonful  given  every 
morning.  AVarmth  and  moisture,  constantly  apjilied  to  the  lower  part 
of  the  abdomen,  give  great  relief — either  in  the  form  of  large  poultices 
of  linseed-meal,  or,  if  these  prove  too  heavy,  of  spongio-piline  soaked 
in  boiling  Mater.  The  poultices  may  be  advantageously  sprinkled  with 
laudanum  or  belladonna  liniment.  I  say  nothing  of  the  use  of  mercu- 
rials, iodide  of  potassium,  and  other  so-called  absorbent  remedies,  since 
I  believe  them  to  be  quite  valueless  and  ajit  to  divert  attention  from 
more  useful  plans  of  treatment. 

The  most  absolute  rest  in  the  recumbent  position  is  essential,  and  it 
should  be  persevered  in  for  some  time  after  the  intensity  of  the  symp- 
toms is  lessened.  The  beneficial  effect  of  rest  in  alleviating  pain  is 
often  seen  in  neglected  cases,  the  nature  of  Avhich  has  been  overlooked, 
instant  relief  folloAving  the  laying  up  of  the  patient. 

When  the  acute  symptoms  have  lessened,  absorjition  of  the  exuda- 
tion may  be  favored  and  considerable  relief  obtained  from  counter-irri- 
tation, which  should  be  gentle  and  long  continued.  The  daily  use  of 
tincture  of  iodine  until  the  skin  jieels  perhaps  best  meets  this  indica- 
tion, but  frequently  repeated  blisters  are  often  very  serviceal)le.  This 
T  believe  to  l)e  a  better  ]ilan  than  keeping  \\\^  an  open  sore  with  savine 
ointment  or  similar  irritating  aii])lications. 

When  su))])uration  is  established  the  question  of  opening  the  abscess 
arises.  When  this  points  in  the  groin  and  the  matter  is  superficial,  a 
free  incision  may  be  made ;  and  here,  as  in  mammary  abscess,  the  anti- 
septic treatment  is  likely  to  prove  very  serviceable.  The  abscess  should, 
however,  not  be  opened  too  soon,  and  it  is  belter  to  wait  until  the  pus 
is  near  the  surface.  The  importance  of  not  being  in  too  great  a  hurry 
to  open  pelvic  abscesses  has  been  insisted  on  by  West,  Duncan,  and 
other  writers,  and  I  have  no  doubt  the  rule  is  a  good  one.  It  is  more 
especially  applicable  when  the  abscess  is  pointing  in  the  vagina  or  rec- 


PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS.  059 

turn,  wlierc  (.■xplomtory  iiici.si<Mi.s  are  apt  to  be  dangerous,  and  when  the 
presence  of  pus  should  be  positively  ascertained  before  operating.  AVe 
have  in  the  aspirator  a  most  useful  instrument  in  the  treatment  of  such 
cases,  which  enal)les  us  to  remove  the  greater  part  of  the  [)us  without 
any  risk,  and  the  use  of  which  is  not  attended  with  danger  even  if 
employed  prematurely.  If  it  do  not  sutHciently  evacuate  the  abscess, 
a  free  opening  can  afterward  be  safely  made  and  a  suitable  di-ainage- 
tube  inserted  into  the  abscess-cavity.  The  surgical  treatment  of  pelvic 
abscess  is,  however,  too  wide  a  subject  to  admit  of  being  satisfactorily 
treated  here. 

The  diet  shoidd  be  abundant,  but  simple  and  nutritious.  In  the 
early  stages  of  the  disease  milk,  beef-tea,  eggs,  and  the  like  will  be 
sufficient.  After  suppuration  a  large  quantity  of  animal  food  is  neces- 
sary and  a  sufficient  amount  of  stimulants.  The  drain  on  the  system 
is  then  often  very  great,  and  the  amount  of  nourishment  patients  will 
require  and  assimilate  when  a  copious  purulent  discharge  is  going  on  is 
often  quite  remarkable.  A  general  tonic  plan  of  medication  is  also 
indicated,  and  such  drugs  as  iron,  quinine,  and  cod-liver  oil  will  prove 
useful. 


iisrr>E5:. 


ABDOMEN,   adiijose,    enlargement   of, 
161 

[color-line  in  pregnant  women,  528] 

enlargement  of,  as  a  sign  of  pregnancy, 
151 

state  of,  after  delivery,  556 
Abdominal  pregnancy.     See  Extra-uterine 

Pregnancy. 
Abortion,  246 

causes  of,  248 

difficidty  in  procuring  artificial,  252 

liability  to  recurrence  of,  248 

[opium  treatment  in  threatened,  254] 

production  of,  in  vomiting  of  pregnancy, 
203 

retention  of  secundines  in,  253,  257 

symptoms  of,  252 

treatment  of,  253 

value  of  opium  in  prevention  of,  253 

[Viburnum  prunifolium  in  threatened, 
254] 
Abscess  of  mammas.     See  Mammary  Ab- 
scess. 

pelvic.     See  Pelvic  Cellulitis. 
After-coming  head,  application  of  forceps 

to,  313 
After-pains,  557 

treatment  of,  559 
Age,  influence  of,  in  labor,  345 
Albuminuria  in  pregnancy,  146,  208 
relation  of,  to  eclampsia,  581 
to  puerperal  insanitv,  591 
Allantois,  108 
Amnii,  li(|Uor,  110 
Anniio-chorionic  fluid,  112 
Anniion,  formation  of,  110 

pathology  of,  239 

structure  of,  110 
Amputations  (intra-uterine),  244 
Ana?mia  in  pregnancy,  207 

[pernicious,  in  parturient  women,  207] 
Anaesthesia  in  labor,  299 

in  forceps  operations,  485 

value  of,  in  difticult  cases  of  turning,  476 
Anasarca  in  pregnancy,  210 
Anteversion  of  the  gravid  uterus,  219 
Antiseptic  midwifery,  611 
Apople.xy  during  or  after  labor,  643 
Arbor  vita',  59 
Area  germinativa,  106 
Area  peliucida,  106 
Areola,  8t) 

changes  of,  during  pregnane}',  150 


Arm,  presentation  of  (see  Shoulder  Presen- 
tation) ;  dorsal  displacement  of,  336 

Arterial  transfusion,  547 

Artificial  human  milk,  575 

resijiration  in  cases   of  apparent   still- 
birth, 563 

Ascites  as  a  cause  of  dystocia,  380 

Aspliyxia  (idiopathic),  643 
of  newborn  children,  562 

Atropine,  hypodermic  injection  of,  in  ri- 
gidity of  cervix,  359 

Auscultatory  signs  of  pregnancy,  156 

BAGS  (Barnes').     See  Dilators. 
Ballottement,  155 
Bandl's  ring,  139,  440 
Basilyst,  the,  515 
Bilobed  uterus,  gestation  in,  193 
Binder,  uses  of,  298 

Bladder,  distension  of,  as  a  cause  of  pro- 
tracted labor,  345 
exfoliation  of  lining  membrane  of,  215 
state  of,  after  delivery,  558 
Blastodermic  membrane,  100 
division  and  layers  of,  10& 
Blastosphere,  99 
Blood,  alteration  in,  after  delivery,  552 

changes  of,  during  pregnancy,  143 
Blood-diseases  transmitted  to  foetus,  241 
Blunt-hook  in  breech  presentation,  314 
Bowels,  action  of,  after  delivery,  561 
Breech  presentations.     See  Pelvic  Presen- 
tations. 
"Broad  ligaments  of  uterus,  69 
Bronchitis  as  a  cause  of  protracted  labor, 

346 
Brow  presentations,  323 

C CESAREAN  section,  335,  364,  404,  519 
causes  of  mortality  al"ter,  524 
causes  requiring  the  operation,  521 
description  of,  528 
history  of,  518 
post-mortem  operation,  523 
results  to  child  in,  521 
statistics  of,  521 
substitutes  for,  533 
sutures  in,  530 
[( "a'sarean  ojieration,  before  labor,  526] 
[causes  of  deatii  from.  525] 
[dangers  of,  overestimated,  406] 
I  in  America,  521] 
[in  cancer  of  the  cervix,  361] 

601 


G(j2 


INDEX. 


[Caesarean  operation  in  impaetion  of  (Ve- 
tus,  335] 
[records  of  tumor  lases,  364] 
[nnder  relative  indications,  •')22] 
Calculus  of  bladder  obstructing  labor,  366 
Ca|)ut  succedaneuni,  283 
Carcinoma  in  pregnancy,  225 

obstructing  labor,  300 
Cardiac  murmurs  in  pulmonary  obstruc- 
tion, 637 
Caries  of  teeth  in  pregnancy,  205 
Carnnculfe  myrtiformes,  53 
Catheter,  introduction  of,  51 
Caul,  268 

Cellulitis,  pelvic.     See  Pelvic  Cellulitis. 
Cephalotribe,  507 
Cephaloti'ipsy.     See  Craniotomy. 
Cervix  uteri,  59 

alterations  of,  after  childbirth,  59 
cavity  of,  59 

dilatation  of,  in  labor,  263 
hypertrophic  elongation  of,  360 
impaction  of,  before  foetal  head,  290 
incision  of,  for  rigidity,  361 
lacerations  of,  445 
modification  of,  by  pregnancy,  139 
mucous  membrane  of,  63 
obstetrical,  440 

organic  causes  of  rigidity  of,  360 
rigidity  of,  as  a  cause  of  protracted  la- 
bor, 358 
treatment  of  rigiditv,  359 
villi  of,  63 
Charlotte,  princess  of  Wales,  death  of,  354 
Child,  the  newborn.     See  Infant. 

risks  to,  in  forceps  operations,  492 
Childbirth,  mortalitv  of,  551 
Chloral,  in  labor,  299 

in  rigidity  of  cervix,  359 
Chloroform  in  labor,  301 

in  difficult  cases  of  turning,  469 
in  rigidity  of  cervix,  359 
Chorea  in  pregnancv,  214 
Chorion,  112  " 
primitive.  113 

vesicular  degeneration  of,  232 
Circulation  of  foetus,  132 
Cleavage  of  yelk,  99 
Clitoris,  51 

Cocaine  in  labor,  547 
Coccyx,  35 

ligaments  of,  37 
moljility  of,  36 
ossification  of,  36 
Cold  in  the  treatment  of  puerperal  hyper- 
pyrexia, 627 
Colostnmi,  564 
Complex  presentations,  335 
Concealed  internal  Jiemorrhage,  420 
Conception,  signs  of,  147 
Constipation  in  pregnancy,  204 
Constriction  of  uterus,  tetanoid.  362 
Continued  fever  in  pregnancy,  223 
Convulsions  (puerperal).     See  Eclampsia. 
Corps  reticul^,  110 


Corpus  luteum,  84 

false,  84 
Cranioclast,  506 
Craniotomy,  504 

cases  requiring,  509 

comparative  merits  of,  and  cephalotrip- 
sy,  512 

description  of  cephalotripsy,  513 

extraction  of  head  by  craniotomy-for- 
ceps,  515 

method  of  perforating,  511 

perforation  of  after-coming  head,  512 

l^erforators,  506 

religious  objections  to,  504 
Craniotomy-forceps,  506 
Crotchets,  506 

Cyclical  theory  of  menstruation,  92 
Cystocele,  olistructing  labor,  366 
[Cysts,    dermoid,    prolapsed,    obstructing 
pelvis,  366] 

DEATH,   apparent,  of  newborn   child. 
See  In/ant. 
from  air  in  the  veins,  644 
functional  causes  of,  643 
organic  causes  of,  643 
sudden,  during  labor  and  the  puerperal 
state,  643 
Decapitation  of  foetus,  517 
Decidua,  101 

at  end  of  pregnancv  and  after  deliverv, 

105 
cavitv  between  decidua  vera  and  reflexa, 

104 
divisions  of,  101 
fatty  degeneration  of,  as  the  cause  of 

labor,  260 
formation  of  decidua  reflexa,  103 
structure  of,  102 
[Deformities,  spinal  and  pelvic,  associated, 

387]- 
Delivery,  state  of  patient  after,  552 
contraction  of  uterus  after,  554 
[Macdurs,  519] 

management  of  patient  after,  558 
nervous  shock  after,  552 
prediction  of  date  of,  165 
signs  of  recent,  168 
state  of  pulse  after,  552 
[very  rapid,  case  of,  357] 
weight  of  uterus  after,  555 
Diabetes,  146 
Diameters  of  foetal  skull,  125 

of  pelvis,  41 
Diarrhoea  in  pregnancy,  203 
Diet  of  lying-in  women,  559 
Differential  diagnosis  of  pregnancy,  161 
Dilators  (caoutchouc)  in  the  induction  of 
premature  labor,  460 
in  rigidity  of  cervix,  360 
Diphtheria  in  the  i)uerperal  state,  606 
Diseases  of  pregnancv,  199 
albuminuria,  208 
ana?mia  and  clilorosis,  207 
carcinoma,  225 


INDEX. 


G6;3 


Diseases  of  pregnancy,  cardiac  diseases,  224 

chorea,  2H 

constipation,  204 

diarrhQ?a,  203 

disorders  of  the  nervous  system,  212 
respiratory  organs,  205 
teetli,  205 
urinary  system,  215 

disphicements  of  gravid  uterus,  218 

epilepsy,  225 

eruptive  fevers,  222 

fibroid  tumors,  227 

hemorrhoids,  204 

icterus,  225 

leucorrlioea,  216 

ovarian  timior,  226 

palpitation,  206 

paralysis,  213 

pneumonia,  223 

pruritus,  216 

ptyalism,  205 

syncope,  206 

syphilis,  224 

varicose  veins,  217 

vomiting  (excessive),  199 
Dropsies  aflecting  the  foetus,  243 
Ductus  arteriosus,  133 

venosus,  133 
Dystocia  from  foetus,  370 

ECLAMPSIA,  578 
cause  of  death  in,  581 

condition  of  patient  between  tlie  attacks, 
580 

confusion  from  defective  nomenclature, 
578 

exciting  causes  of,  583 

obstetric  management  in,  586 

pathology  of,  581 

premonitory  symptoms  of,  579 

relation  of,  to  labor,  580 

results  to  mother  and  child  in,  581 

symjjtoms  of,  579 

transfusion  in,  549 

Traiibe  and  Rosenstein's  theory  of,  582 

treJitment  of,  583 

unemic  theory  of,  581 

venesection  in,  584 

views  of  MacDonald,  583 
Ecraseur,  use  of,  as  a  substitute  for  crani- 
otomy, 508 
Embolism.     See  Thrombosis. 
Embryotomy,  516 
Emotion,  mental,  as  a  cause  of  proti'acted 

labor,  346 
Epi  blast,  106 

Epilepsy  in  pregnancy,  225 
Epileptic  convulsions,  578 
Ergot  of  rye,  348 

as  a  means  of  inducing  labor,  459 

mode  of  administration,  348 

objections  to  use  of,  348 

value  of,  after  delivery,  298 
Ergotine,  hypodermic  injection  of  in  post- 
partum liemorrhage,  428 
Eruptive  fevers  in  pregnancy,  222 


Erysipelas  as  a  cause  of  puerperal  septica;- 

mia,  605 
Etlier  in  labor,  301 

[safer  to  inhale  than  cldoroform,  302, 
303] 
Evisceration,  518 

Exhaustion,  importance  of  distinguisliing 
between  temporary  and  permanent, 
in  labor,  348 
[Exostosis,  pelvic,  an  obstruction  to  deliv- 
ery, 395] 
Expression,  uterine  (see  Pressure) ;  of  tlie 

placenta,  296 
Extra-uterine  pregnancy,  176 
abdominal  variety  of,  185 
causes  of,  177 

changes  of  the  foetus  in,  186 
classification  of,  176 
diagnosis  of  abdominal  variety,  188 

of  tubal  variety,  181 
gastrotomy  in,  185,  190 
pseudo-labor  in,  187 
symptoms  of  rupture  in,  181 
treatment  after  rupture,  185 
of  abdominal  variety,  189 
tubal  variety,  179 

treatment  of  tubal  variety,  183 
vaginal  section  in,  183 
Eye,  diseases  of,  in  pregnancy,  225 

FACE  presentation,  315 
causes  of,  315 
diagnosis  of,  316 
difiiculties  connected  with,  322 
erroneous  views  formerly  entertained  of, 

315 
mechanism  of  delivery  in,  317 
mento-posterior  positions  in,  320 
prognosis  in,  321 
treatment  of,  322 
Fallopian  tubes,  71 
False  corpus  luteum,  84 
False  pains,  character  and  treatment  of, 

287 
Faradization  in  apparent  stillbirth,  563 
in  destroying  the  vitality  of  the  foetus  in 

abnormal  pregnancies,  183 
in  hemorrhage  after  delivery,  432 
in  labor,  350 
[Fatigue,  recurrent  uterine,  346] 
Fibroid  tumor  in  pregnancy,  227 

obstructing  labor,  363 
Fillet,  503 

in  breech  presentations,  314 
nature  of  the  instrument,  503 
objections  to  its  use,  503 
Flattened  pelvis,  305 
Foetal  head,  anatomy  of,  123 

induction  of  premature  labor  for  large 
size  of,  457 
heart,  sounds  of,  in  jiregnancy,  156 
Foetus,  anatomy  and  physiology  of,  121 
appearance  of  a  putrid,  246 

of,  at  various  stages  of  development, 

121 
at  term,  122 


664 


INDEX. 


Foetus,  circulation  of,  132 

changes  in  circulation  of,  as  cause  of  la- 
bor, 254 
in    position    of,    during    pregnancy, 
126 
death  of,  245 

detection  of  position  in  utero  by  palpa- 
tion, 127 
early  viability  of,  247 
excessive  development  of,  as  a  cause  of 
1      difficult  labor,  381 
explanation  of  its  position  in  utero,  128 
functions  of,  130 
nutrition  of,  130 
pathology  of,  241 
position  of,  in  idero,  126 
respiration  of,  131 
signs  and  diagnosis  of  death  of,  246 
[Foetuses,  very  small,  habitually  produced 

by  some  mothei's,  128] 
Fontanelles,  124 
Foot,  diagnosis  of,  306 
Foot  presentations.     See  Pelvic  Presenta- 
tions. 
Foramen  ovale,  132 
Forceps,  478 
action  of,  482 

advantage  of  pelvic  curve  in,  479 
application  of,  to  after-coming  head  in 
breech  presentations,  312 
within  the  cervix,  361 
[breech,  314] 
cases   in   which   a  straight  instrument 

should  be  used,  480 
dangers  of,  353,  491 

to  child,  492 
descrijjtion  of,  478 

the  operation,  485 
difl'erence  between  high  and  low  opera- 
tions, 484 
disadvantages  of  a  weak  instrument,  481 
[frequent  use  of,  355,  356] 

in  modern  practice,  352,  478 
high  operations,  490 
[in  America,  492-501] 
long,  480 

[Meigs'  craniotom.y,  516] 
preliminary  considerations  before  using, 

485 
short,  478 
use  of  anaesthetics  in  forceps  delivery, 

485 
use  of,  in  deformed  pelvis,  401 

in  difficult  occipito-posterior  positions, 

326 
in  protracted  labor,  352 
Forceps-saw,  508 
Fossa  navicularis,  53 
Funis.     See  Umbilical  Cord. 

[corkscrew-formed,  238] 
Funnel-shaped  pelvis,  385 

GALACTAGOGUES,  569 
Galactorrhcea,  570 
Galvanism  as  a  .means  of  inducing  labor, 
459 


Gangrene  of  limbs  from  arterial  obstruc- 
tion, 642 
Gastrotomy,  after  rupture  of  uterus,  444 

in  extra-uterine  pregnancy,  185,  190 
Gastro-elytrotomy.     See  Laparo-elytrotomy. 
Generative  organs  in  the  female,  49 

division  according  to  function,  49 
Germinal  vesicle,  disappearance  of,  after 

impregnation,  99 
Gestation.     See  Pregnancy. 
Glycosuria  in  pregnancy,  146 

in  lactation,  554 
Graafian  follicle,  75 
structure  of,  77 

HEMATOCELE,  obstructing  labor,  367 
Hand-feeding  of  infants,  574 

artificial  human  milk  in,  575 

ass's  milk  in,  575 

causes  of  mortality  in,  574 

cow's  milk  in,  and  its  preparation,  575 

goat's  milk  in,  575 

method  of,  577 
Head  presentations,  272 

descri|)tion  of  cranial  positions  in,  272 

division  of,  273 

explanation  of,  274 

frequency  of  first  position,  274 

mechanism  of  first  position,  274 

second  position,  280 

third  position,  280 

fourth  2^osition,  283 

relative  frequency  of  various  positions, 
273 
Heart,  diseases  of,  in  pregnancy,  224 
hypertrophy  of,  in  pregnancy,  144 
Hemorrhage,  accidental,  418 

causes  and  pathology  of,  419 

concealed  internal,  420 

diagnosis,  prognosis,  and  treatment  of 
concealed  internal,  420 

prognosis  of,  420 

symptoms  and  diagnosis  of,  419 

treatment  of,  421 
after  delivery,  421 

causes  of,  422 

constitutional  predisposition  to,  426 

curative  treatment  of,  428 

from  laceration  of  maternal  structures, 
434 

nature's  mode  of  preventing,  270,  422 

preventive  treatment  of,  427 

secondary  causes  of,  424 
treatment  of,  434 

symptoms  of,  426 

transfusion  of  blood  in,  434 

vinegar  as  a  styptic  in,  434 

(secondary),  434 
distinction  between,  and  profuse  lochial 
discharge,  435 

local  causes  of,  436 

treatment  of,  437 

unavoidable.     See  Placenta  Prcevia. 
Hemorrhoids,  in  pregnancy,  204 
Hernia,  in  labor,  367 
Hour-glass  contraction  of  uterus,  424 


INDEX. 


665 


Hour-glasfe  contraction,  ante-partum,  362 
Hydatids  of  uterus,  231 
Hydraianios,  239  [240] 
Hydrocephalus  of  foetus  as  a  cause  of  dif- 
ficult labor,  378 
Hydrorrhoea  gravidarum,  230 
Hymen,  52 
Hypoblast,  106 
Hysteria  during  labor,  578 

TCTEEUS,  225 

JL   [Impaction  of  bowels  from  eating  clay 

an  obstacle  to  delivery,  367] 
Induction  of  premature  labor.     See  Pre- 
mature Labor. 
Inertia  of  the  uterus,  frequent  child-bear- 
ing as  a  cause  of,  345 
Infant,  apparent  death  of,  562 

appearance   of,   in    cases    of    apparent 

death,  562 
clothing  of,  564 
evils  of  over-suckling,  565 
management  of,  566 

when  food  disagrees,  577 
treatment  of  apjjarent  death  of,  562 
various  kinds  of  food  of,  577 
washing  and  dressing  of,  564 
Infantile   mortality,   diminution  of,   as   a 
reason  for  more  frequent  use  of  for- 
ceps, 352 
Inflammatory  diseases  aflfecting  the  foetus, 

242 
[Injections,  uterine,  of  hot  water,  431] 
Insanity  (puerperal),  594 
classification  of,  587 
of  lactation,  593 
of  pregnancy,  588 
predisposing  causes  of,  589 
puerperal  (proper),  590 
causes  of,  591 
form  of,  prognosis  of,  589 
post-mortem  signs  of,  598 
question  of  removal  to  an  asylum,  597 
symptoms  of,  593 

transient  mania  during  delivery,  590 
treatment  of,  595 

during  convalescence,  597 
Insomnia  in  pregnancy,  212 
Intermittent  fever  affecting  the  foetus,  241 
Intestines,  disorders  of,  as  influencing  labor, 

345 
Inversion  of  uterus.     See  Uterus. 
Involution  of  uterus,  554 
Irregular  uterine  contractions  after  labor, 
424 
as  a  cause  of  lingering  labor,  347 
Irritable  bladder  in  pregnancy,  215 
Ischium,  planes  of  the,  46 

TAUNDICE  in  pregnancy,  225 

KIESTEIN,  146  _ 
Knee  presentation,  306 
Knots  on  the  umbilical  cord,  238 
Kyphotic  deformity  of  pelvis,  393 


LABIA  majora,  49 
Labia  minora,  50 
Labor,  259 

age,  influence  of,  on,  345 
anpesthesia  in,  299 
arrest  of,  168 
causes  of,  259 

[of  missed,  196-199] 
of  precipitate,  356 
of  protracted,  343 
character  and  source  of  pain  in,  265 

of  false  pains,  267 
cocaine  in,  347 
dilatation  of  cervix  in,  263 
duration  of,  271 

effect  of  uterine  contractions  in,  261 
evil  effects  of  protracted,  342 
induction  of     See  Premature  Labor. 
influence  of  stage  of,  in  protracted,  343 
management  of,  in  deformed  pelvis,  400 
of  natural,  284 
of  third  stage  of,  294 
mechanism  of,  in  head  presentation,  272 
obstructed  by  faulty  condition  of  the  soft 

parts,  358 
period  of  day  at  which  labor  commences, 

271 
phenomena  of,  259 
position  of  patient  during,  288,  290   . 
precipitate,  352 
preparatory  treatment,  284 
prolonged  and  precipitate,  842 
rupture  of  membranes  in,  263 
stages  of,  263 

symptoms  of  protracted,  344 
treatment  of  protracted,  347 
Lactation,  defective  secretion  of  milk  in, 
569 
diet  of  nursing  women  during,  567 
diseases  of  the  eye  during,  571 
evil  results  of  prolonged,  565 
excessive  flow  of  milk  in,  570 
importance  of,  to  mother,  565 
of  wet-nursing  to  child,  565 
insanity  of,  593 
management  of,  567 
means  of  arresting  secretion  of  milk  in, 

568 
period  of  weaning  in,  568 
Lamina?  dorsales,  106 
Laparo-elytrotomy,  534 

[inadmissible  in  many  Csesarean  cases, 

535] 
[performed  on  either  side,  537] 
[statistics  of,  535] 
Lead-poisoning,  affecting  tlie  foetus,  241 

as  a  cause  of  abortion,  251 
Leucorrlioea,  in  pregnancy,  216 
Lever.     See  Ft'c//'s. 
Liojuor  amnii,  110 
deficiency  of,  241 
source  of,  112 
spurious,  112 
uses  of,  112 
Lithopjedion,  188 
Liver,  acute  yellow  atrophy  of,  225 


666 


IXBEX. 


Liver,  changes  of,  in  pregnancy,  145 
lyochia,  556 

occasional  fetor  of,  557 

vai'iation  in  amount  and  duration  of,  557 
Lying-in  hospitals,  mortality  in,  589 
Lypothemia,  150,  206 

iyiALAEL\L  puerperal  fever,  622 

ifl  Malpresentations,   iieculiar    form    of 

bag  of  membranes  in,  305 
Mammary  abscess,  571  l 

antiseptic  treatment  of,  572 
signs  and  symptoms  of,  571  ! 

treatment  of,  572 
changes  during  pregnancy,  150 

their  diagnostic  value,  151  i 

glands,  79 

their  sympathetic  relations  with  the  j 
uterus,  81  I 

Mania,  puerperal.  See  Insanity,  Puerperal. 
Mastitis,  571 
Measles,  aflecting  the  foetus,  241 

in  pregnancy,  223 
Meconium,  135 

Membranes,  artificial  rupture  of,  289 
puncture  of,  as   a   means   of   inducing 
labor,  458 
Menstruation,  81 
cessation  of,  93 

changes  in  Graafian  follicle  after,  82 
during  pregnancy,  148 
[from  unimpregnated  side  of  a  double 

uterus,  146] 
period  of,  duration,  and  recurrence,  87 
purpose  of,  92 

quantity  of  blood  lost  in,  88 
sources  of  blood  in,  89 
theory  of,  90 
vicarious,  93 
Mesoblast,  106 
Milk,  artificial  human,  575 
ass's,  575 

cow's,  and  its  preparation,  575 
defective  secretion  of,  569 
[diet  for  nursing  mothers,  569] 
excessive  secretion  of,  570 
goat's,  575 

means  of  arresting  the  secretion  of,  568 
secretion  of,  after  delivery,  565 
transfusion  of,  544 
Milk  fever,  553 
Miscarriage.     See  Abortion. 
Missed  labor,  194 
Moles,  250 

Monstro.sity  (double),  374 
classification  of,  374 
mechanism  of  delivery  in,  375 
Mons  Veneris,  49 
^lontgomery's  cujjs,  103 
Morning  sickness,  149 
Mortality  of  childbirth,  551 

[of  infants  delivered   by  induction  of 
pren:ature  labor,  463] 
]Mucous  membrane  of  uterus.    vSee  Uterus. 
Miiiler's  operation,  532 
Myxoma  fibrosum,  234 


VfERVOUS  shock  after  delivery,  552 

IN    Nervous  system,  changes   in,   during 
pregnancy,  145 
disorders  of,  in  pregnancy,  212 
excitability  of,  in  puerperal  Avomen,  583 

Neuralgia  in  pregnancv.  213 

Nipple,  80 

Nipples,  depressed,  569 

fissures  and  excoriations  of,  570 

Nursing.     See  Lactation. 

Nutrition  of  fretus,  130 

Nymphse.     See  Labia  Minora. 

OBLIQLELY-contracted  pelvis,  392 
Obstetric  bag,  285 
Obstetrical  cervix,  440 
Occipito-posterior  positions,  difficult  cases 
of,  324 
causes   of   face-to-pubes   deliverv  in, 

325 
forceps  in,  326 
treatment  of,  325 
vectis  or  fillet  in,  325 
Omphalo-mesenteric  artery  and  vein,  108 
Opiates,  use  of,  after  delivery,  558 
Os  innominatum,  33 
Osteomalacia,  as  a  cause  of  deformity,  38S 

[not  an  American  disease,  392] 
Osteophytes,  formation   of,   during   preg- 
nancy, 145 
Os   uteri,    constriction   of    internal,    as   a 
cause  of  dystocia,  362 
dilatation  of,  as  a  means  of  inducing 

labor,  460 
occlusion  of,  in  labor,  360 
Ovarian    pregnancy.       See    Extra-uterine 
Pregnancy. 
tumor  in  pregnancy,  226 
Ovariotomy  in  pregnancy,  226 
Ovary,  73 

functions  of,  81 
structure  of,  74 
vascular  arrangements  of,  78 
Ovule,  78 

changes  in,  after  impregnation,  98 
when  retained  in  utero  after  its  death, 
250 
formation  of,  75 
Ovum,  blighted,  retained  in  utero,  250 
Oxytocic  remedies,  348 

PAINS,  after-,  557 
false,  286 
irregular  and  spasmodic,  as  a  cause  of 

protracted  labor,  347 
labor-,  265 
Palpitation  in  jiregnancy,  206 
Pampiniform  plexus,  66 
Paralysis  in  pregnancy,  213 

from  embolism  of  the  cerebral  arteries, 
642  • 

from  embolism  of  the  main  arteries  of 
the  limb,  642 
Parovarium,  69 
Parturient  canal,  axis  of,  44 
Pathology  of  decidua  and  ovum,  229 


INDEX. 


667 


Pelvic  cellulitis  and  peritonitis,  652 

connection  with  septicaemia,  653 

etiology  of,  653 

importance  of  distinguishing  the  two 
forms  of  disease,  653 

opening  of  abscess  in,  658 

prognosis  of,  657 

relative  frequency  of  the  two  forms 
of  disease,  655 

results  of  physical  examination,  655 

seat  of  inflammation  in  cellulitis,  654 
in  peritonitis,  654 

suppuration,  in,  656 

symptomatology,  655 

terminations  of,  656 

treatment  of,  657 

two  distinct  forms  of  disease,  652 
Pelvic  presentations,  303 

application  of  forceps   to   the   after- 
coming  head  in,  313 

causes  of,  304 

danger  to  children  in,  304 

diagnosis  of,  305 

frequency  of,  304 

management  of  impacted  breech  in, 
313 

mechanism  of,  306 

prognosis  in,  304 

treatment  of,  310 
Pelvis,  alterations  in  articulations  of,  dur- 
ing pregnancy,  39 
anatomy  of,  33 
articulations  of,  36 
axes  of,  44 

Cfesarean  section  in  deformities  of,  404 
causes  of  deformity  of,  382 
comparative   estimate    of   turning   and 

forceps  in  deformity  of,  404 
[coxalgic  deformity  of,  392] 
craniotomy  in  deformity  of,  404 
diagnosis  of  deformity,  398 
deformities  of,  382 
development  of,  46 
difference  according  to  race,  47 
differences  in  the  two  sexes,  40 
division  into  true  and  false,  34 
equally  contracted,  384 

enlarged,  384 
flattened,  385 

forceps  in  deformity  of,  401 
funnel-shaped,  385 

induction  of  premature  labor  in  deform- 
ity of,  404 
infantile,  46 
kyphotic,  393 
ligaments  of,  37 
masculine,  385 

mechanism  of  delivery  in  deformed,396 
movements  in  the  articulations  of,  38 
obliquely  contracted,  392 
planes  of,  43 
Kobert's,  393 
scoliotic,  387 

[small,    masked    by   external    develop- 
ment of  adipose  tissue,  384] 
soft  parts  connected  with,  48 


Pelvis,  tumors  of,  394 

turning  in  deformity  of,  402 
undeveloped,  384 
Pelvimeters,  various  forms  of,  398 
Perchloride  of  iron,  injections  of,  in  post- 
partum hemorrhage,  433 
Perforation  of  after-coming  head,  512 
Perforators,  505 

Perineum,  distension  of,  in  labor,  269,  291 
incision  of,  292 
laceration  of,  293 
relaxation  of,  291 

rigidity  of,  as  a  cause  of  protracted  la- 
bor, 363 
Peritonitis,  pelvic.     See  Pelvic  Cellulitis. 

puerperal.     See  Septiccemia. 
Phlegmasia  dolens.      See   Thrombosis,  pe- 
ripheral venous. 
Placenta,  adhesion  of,  after  delivery,  425 
degeneration  of,  119 
detachment  of,  in  labor,  269 
diseases  of,  235 
expression  of,  296 
[expulsion  of,  295] 
fo?tal  portion  of,  115 
form  of,  in  man  and  animals,  114 
formation  of,  from  chorion,  113 
functions  of,  119 
maternal  portion  of,  116 
minute  structure  of,  115 
pathology  of,  234 
sinus,  system  of,  117 
sounds  produced  during  separation  of, 

160 
treatment  of  adherent,  430 

of,  in  extra-uterine  foetation,  191 
Placenta  membranacea,  234 
Placenta  pnevia,  407 
causes  of,  407 

causes  of  hemorrhage  in,  410 
natural  termination  of  labor  in,  411 
pathological  changes  of  placenta  in, 

411 
pi'ognosis.  in,  412 
sources  of  hemorrhage  in,  409 
summary  of  rules  of  treatment  in,  417 
symptoms  of,  408 
treatment  of,  413 
turning  in,  416 
Placentfe  succenturife,  235 
Placentation,  metadiscoidal,  114 

discoid  al,  114 
Placentitis,  236 
Plugging  of  vagina,  256 
Plural  births,  170,  370 

arrangement  of  placentge  and  mem- 
branes in,  172 
causes  of,  171 
diagnosis  of,  173 
relative    frequency    of,    in    diflerent 

countries,  170 
sex  of  children  in,  171 
treatment  of  370 
Pneumonia  in  pregnancy,  223 

puerperal  embolic,  639 
"Polar  globule,"  99 


668 


INDEX. 


[Polypus,  an  obstacle  to  labor,  3G9] 
Porro's  operation,  531 

[followed  by  crural  phlebitis,  650] 
[in  Great  Britain,  532] 
[statistics,  532] 
Position  of  cranium  in  head  presentation. 

See  Head  Presentation. 
Post-partum    hemorrhage.      See    Hemor- 
rhage. 
Pregnancy,  136 
abnormal,  170 

affections  of  respiratory  organs,  205 
alteration  of  color  of  vaginal  mucous 

membrane,  as  a  sign  of,  155 
ballot  tement,  as  a  sign  of,  155 
changes  in  the  blood  during,  143 
changes  in  the  liver,  lymphatics,  and 

spleen  during,  144 
changes  in  the  urine  during,  145 
cocaine  in,  201.     Vide  Labor. 
complicated  with  ovarian  tumor,  226 

■with  fibroid  tumor,  227 
[cough  of,  206] 
deposits  of  pigmentarv  matter  during, 

152  _ 
diabetes  in,  212 
difierential  diagnosis  of,  161 
diseases  of  eye  during,  225 
dress  of  patient  in,  285 
duration  of,  164 
[dyspnoea  of,  206] 
[eneuresis  of,  216] 
enlargement  of  abdomen  as  a  sign  of, 

152 
extra-uterine    (see    Extra-uterine   Preg- 
nancy), [183,  184] 
[exsective  operation  where  the  foetus 

IS  living  and  viable,  191,  192] 
fojtal  movements  in,  153. 
[toxic   injection   of   cvst,   dangerous, 
184] 
formation  of  osteophytes  during,  145 
hypertrophy  of  the  heart  during,  144 
in  cases  of  double  uterus,  67 
in  the  absence  of  menstruation,  148 
intermittent  uterine   contractions,  as  a 

sign  of,  153 
liver,  changes  of,  in,  145 
prolapse  of  the  uterus  in,  218 
protraction,  166 
pruritus  in,  216 
ptyalism  in,  205 
quickening,  153 
sickness  of,  149 
signs  and  diagnosis  of,  147 
sounds    produced   by  the  foetal   move- 
ments in,  160 
spurious,  163 

sympathetic  disturbances  of,  149 
tetanus  in,  215 
uterine  fluctuation  in,  155 
vaginal  signs  of,  154 
pulsation  in,  155 
Premature  labor,  247 

historv  of  the  operation  of  induction 
of,  456 


Premature  labor,  induction  of,  456 
in  deformed  pelvis,  404 
injection  of   carbonic  acid  gas   as   a 

means  of  inducing,  462 
insertion    of    flexible    bougie    as    a 

means  of  inducing,  462 
objects  of  the  operation  of  induction 

of,  456. 
oxytocics  as  a  means  of  inducing,  459 
period   for   the   induction  of,  in  de- 
formed pelvis,  406 
precautions  as  regards  the  child   in 

the  induction  of,  463 
puncture    of    the    membranes    as    a 

means  of  inducing,  458 
separation   of    the   membranes    as   a 

means  of  inducing,  461 
vaginal    and   uterine    douches    as    a 
means  of  inducing,  461 
Pressure  as  a  means  of  inducing  uterine 
contractions,  350 
mode  of  applying,  351 
Prolapse  of  umbilical  cord.      See  Umbil- 
ical Cord. 
Pronucleus,  female,  99 

male,  99 
[Protector  for  Iving-in  bed,  Kellv's  rub- 
ber, 286]  ■ 
Pseudo-labor,  187 
Ptyalism  in  pregnancy,  205 
Puerperal  convulsion.     See  Eclampsia. 
fever.     See  Septiccemia. 
mania.     See  Insanity. 
jjneumonia,  640 
state,  551 

after-treatment  in,  561 
diet  and  regimen  in,  558 
diminution  of  uterus  in,  554 
importance  of  prolonged  rest  in,  561 
pulse  in,  552 

secretions  and  excretions  in,  553 
temperature  in,  553 
[Pullulation,  arrested,  245] 
Pulmonary  arteries,  anatomical  arrange- 
ment  of,   as   favoring   thrombosis, 
632 


Q 


UICKENING,  153 
Quinine  as  an  oxytocic,  349 


RACE,   as   influencing   the  size   of  the 
fcetal  skull,  126 
Recto-vaginal  fistula,  446 
Respiration  of  fcetus,  131 
Retroversion  of  the  gravid  uterus,  219 
Rickets  as  a  cause  of  pelvic  deformitv,  383 
Ringof  Bandl,  J39,  440 
Rosenmiiller,  organ  of.     See  Parovarium. 
Round  ligaments  of  the  uterus,  71 
Rules  for  monthly  nurses,  560 
Rupture  of  uterus.     See  Uterus. 

SACRUM,  anatomy  of,  35 
mechanical  relations  of,  35 
Salivation  in  pregnancy,  205 
Scarlet  fever  afiecting  the  fcetus,  241 


INDEX. 


669 


Scarlet  fever,  in  pregnancy,  223 
in  the  puerperal  state,  605 
Scoliotic  deformity  of  pelvis,  387 
Scybala;  in  the  rectum  obstructing  labor, 

367 
Septicaemia  (puerperal),  598 
bacteria  in,  612 
channels  of  difiusion  in,  613 

thn)ugh  which  septic  matter  may  be 
absorbed,  602 
cold  in  treatment  of,  627 
conduct    of   practitioner    in    regard   to, 

611 
contagion  from  other  puerperal  patients 

as  a  cause  of,  609 
description  ol',  618 
division  in  auto-genetic  and  hetero-gen- 

etic  forms,  603 
epidemics  of,  600 
history  of,  599 
importance  of  antiseptic  precautions  in, 

611 
influence  of  cadaveric  poison  as  a  cause 
of,  604 
of  zymotic  disease  in  causing,  605 
its  connection  with  pelvic  cellulitis  and 

peritonitis,  653 
local  changes  in,  613 
malarial,  622 

mode  in  which  the  poison  may  be  con- 
veyed to  patients  in,  610 
mortality  in  lying-in  hospitals,  599 
nature  of  septic  poison,  612 
pathological  phenomena  in,  614 
prevention  of,  612 
pypemic  forms  of,  621 
sewer  gas  as  a  source  of  infection,  607 
sources  of  auto-infection  in,  603 

of  hetero-infection,  604 
symptoms  of  the  intense  forms,  618 
theorv   of  an   essential   zvmotic   fever, 
601 
of  identitv  with  surgical  septicaemia, 

601 
of  local  origin,  600 
treatment  of,  622 
venesection  in,  626 

Warburg's  tincture  in  the  treatment  of, 
627 
Sex,  discovery  of,  of  fcetus  during  preg- 
nancy, 157 
of  foetus  as  influencing  the  size  of  the 
skull,  126 
Shoulder  presentations,  328 
diagnosis  of,  331 
division  of,  328 
mechanism  of,  332 
prognosis  and  frequency  of,  330 
spontaneous  version  in,  333 

evolution  in,  333 
treatment  of,  335 
Siamese  twins,  how  born,  375 
Sickness  of  pregnancy,  149 
Smallpox  affecting  the  foetus,  241 

in  yjregnancy,  222 
Smith's,  Tyler,  theory  of  labor,  261 


Spondyl-olisthesis,  388  [389] 
Spondylolizeraa,  390 
Spontaneous  evolution,  333 

version,  333 
Spurious  liquor  amnii,  112 

pregnancy,  163 
diagnosis  of,  164 
symptoms  of,  1 63 
[Statistics  of  old  Caesarean  operations  of 

little  practical  value  now,  520] 
Stillbirtli,  apparent,  562 

treatment  of,  562 
Subzonal  membrane,  107 
Sugar,  in  urine  of  pregnancy,  146 
Superfecundation  and  superfoetation,  173 
[Sutures  in  CVsarean  operations,  530] 

of  fcetal  liead,  124 
Symphysiotomy,  533 

[in  Naples,  533] 
Syncope  during  or  after  labor,  643 

in  pregnancy,  206 

[relieved   by  elevating   the   body   and 
lowering  the  head,  432] 
Syphilis  affecting  the  foetus,  242 

as  a  cause  of  abortion,  251 

in  pregnancy  224 

TEMPERATURE  after  delivery,  553 
Tetanus  in  pregnancy,  215 
Thrombosis  (peripheral  venous),  645 
changes  in  thrombi  in,  649 
condition  of  the  affected  limb,  646 
detachment  of  emboli  in,  649 
history  and  pathology  of,  647 
progref^s  of  the  disease,  647 
symptoms  of,  645 
treatment  of,  650 
(puerperal),  629 
arterial  thrombosis  and  embolism,  641 
cardiac  murmur  in  pulmonary,  637 
cases  illustrating  recovery  from  pulmo- 
nary, 635 
causes  of  death  in  pulmonary,  638 
clinical  facts  in  favor  of  pulmonary,  633 
conditions  which    favor   thrombosis  in 

the  puerperal  state,  631 
distinction  between  thrombosis  and  em- 
bolism, 631 
phlegmasia  dolens  a  consequence  of,  629 
post-mortem  appearance  of  clots  in  pul- 
monary, 638 
pulmonary,  as  a  cause  of  plearo-pneu- 

monia,  640 
question   of  primary  thrombosis  in  the 
pulmonary  arteries,  632 
of  recovery  from  pulmonary,  634 
symptoms  of  arterial,  641 

of  pulmonary  obstruction  in,  634 
treatment  of  arterial,  642 
of  pulmonary,  639 
of  uterine  vessels,  422 
Thi'ombus.     See  Hrematocele. 
Toothache  in  pregnancy,  205 
Transfusion  of  blood,  539 

addition  of  chemical  reagents  to  prevent 
coagulation  of  fibrin,  542 


670 


INDEX. 


Transfusion  of  blood,  cases  suitable  for  tlie 
operation,  544 
dangers  of  the  operation,  544 
defibrination  of  blood  in,  548 
diflficulties  of  the  operation,  541 
effects  of  successful  transfusion,  550 
histoi'y  of  tlie  operation,  589 
immediate  transfusion,  541 
metiiod  of  injecting  defibrinated  blood, 
549 
of  performing  immediate  transfusion, 

546 
of  preparing  defibrinated  blood,  548 
nature  and  object  of  the  operation,  540 
Scliiifer's  directions  for  immediate,  546 
secondary  effects  of,  549 
statistical  results  of,  544 
[with  defibrinated  blood,  550] 
Tropics,  infiuence  of  residence  in,  on  labor, 

345 
Trunk,  presentation  of.    See  Shoulder  Pres- 
entations. 
Tumors,  diagnosis  of  uterine  and  ovarian, 
162 
foetal,  243 

obstructing  labor,  3S0 
(maternal)  obstructing  delivery,  363 
Tunica  albuginea,  75 
Turning,  464 

after  perforation,  512 

antesthesia  in,  469 

[Braxton  Hicks'  bimanual  method  in 

placenta  prtevia,  418] 
by  combined  method,  470 
by  external  manipulation  only,  466 
cases  suitable  for  the  operation,  466 

for  operating  by  combined  method,  465 
cephalic,  464 

choice  of  hand  to  be  used,  469 
history  of  the  operation,  464 
in  abdomino-anterior  positions,  475 
in  deformed  pelvis,  415 
in  placenta  prsevia,  415,  475 
method  of  cephalic,  467 

of  performing  by  external   manipu- 
lation, 466 
of  podalic,  472 
object  and  nature  of  the  operation,  465 
period   when  the  operation  should  be 

performed,  469 
podalic,  469,  472 
position  of  patient  in,  468 
statistics  and  dangers  of,  465 
value  of  antesthetics  in  diflBcult  cases  of, 
476 
Twins.     See  Plural  Birihs. 
[Carolina,  how  born,  377] 
conjoined,  374 
locked,  371 

TTMBILTCAL  cord,  119 
U    knots  of,  120,  238 

lisjature  of,  294 

pathology  of,  238 

prolapse  of,  337 

diagnosis  of  prolapse  of,  339 


Umbilical    cord,    prolajise    of,   causes   of, 
339 
frequency  of,  337 
postural  treatment  of,  340 
prognosis  of,  338 
reposition  of,  341 
treatment  by  laceration,  293 
Umbilical  souffle,  159 

vesicle,  108 
Urachus,  109 

Uriiemia,  in  connection  with  eclampsia,  581 
in  connection  with  puerperal  insanity, 
591 
Urethra,  52 

Urine,  changes  in,  during  pregnancy,  145 
retention  of,  after  delivery,  558 
[to  be  examined  at  once  in  eclamptic 
cases,  587] 
[Uterine  contractions  during  gestation,  in- 
termittent, and  sometimes  painful. 
154] 
fluctuation,  as  a  sign  of  pregnancy,  155 
[rupture,  rational  treatment  of,  448,  449] 
souffle,  159 
Utero-sacral  ligaments,  71 
Uterus,  56 

analogy  of   interior  of,  after  delivery, 
and  stump  of  an  amputated   limb, 
105 
anomalies  of,  67  ' 

ante-partum  hour-glass  contraction,  362 
arrangement  of  muscular  fibres  of,  61 
axis  of,  during  pregnancy,  138 
changes  in  cervix  during  pregnancy,  139 
in    form    and  dimensions   of,  during 

pregnancy,  136 
in  mucous  membranes  of,  after  deliv- 
ery, 554 
in    mucous   membranes   of,  after  im- 
pregnation, 100 
in  tissues  of,  during  pregnancy,  141 
in  the  vessels  of,  after  delivery,  555 
congestive  hypertrophy  of,  162 
contractions  of,  in  labor,  262 
dimensions  of,  58 

diminution  in  size  of,  after  delivery,  554 
distension  of,  as  a  cause  of  labor,  260 

by  retained  menses,  161 
fatty  transformation  of,  after  deliverv, 

^555 
gastrotomy  in,  444 
hour-glass  contraction,  424 
intermittent  contractions  of,  during  preg- 
nancy, 153 
internal  surface  of,  59 
inversion  of,  449 
[inverted,  spontaneous  reposition  of  the, 

454,  455] 
involution  of,  554 

differential  diagnosis  of,  451 

production  of,  451 

results   of  phvsical   examination  in, 

450 
symptoms  of,  450 
treatment  of,  453 
ligaments  of.  69 


INDEX. 


671 


Uterus,  lymphatics  of,  66 

malposition  of,  as  a  cause  of  protracted 

labor,  346 
mode  of  action  in  labor,  264 
mucous  membrane  of,  62 
muscular  fibres  of,  61 
nerves  of,  66 
[partitioned,  68] 
regional  division  of,  59 
relations  of,  57 
retroversion  of  gravid,  220 
rupture  of,  438 

alterations  of  tissues  in,  439 

causes  of,  439 

comparative  result  of  various  methods 
of  treatment  in,  444 

prognosis  of,  443 

seat  of  laceration  in,  438 

symptoms  of,  441 

treatment  oi",  443 
size  of,  at  various  periods  of  pregnancy, 

137  _ 
state  of,  in  protracted  labor,  344 
structures  composing,  60 
utricular  glands  of,  62 
vessels  of,  64 
weight  of,  after  delivery,  555 

YAGINA,  53  'f  .  ;,  _ 

V    bands   and  cicatrices   of,   obstructing 
,  delivery^..  360 
contraction  of,  after  delivery,  556 
lacerations  of,  445 
orifice  of,  52    ■ 
structure  of,  54 
A'^aricose  veins  in  pregnancy,  217 


^ 


Vectis,  502 

action  of,  502 

cases  in  which  it  is  applicable,  502 
Veins,  entrance  of  air  into,  as  a  cause  of 

sudden  death  after  delivery,  644 
Venesection  for  rigidity  of  cervix,  361 
A'^ersion.     Se6  Ttirnimj. 

[bimanual,  in  breech  cases,  305] 

[by  the  vertex,  327] 
Vesico-uterine  ligaments,  71 
Vesico- vaginal  fistula,  446 
Vestibule,  51 

Vicarious  menstruation,  93 
Vinegar  as  a  styptic  in  post-partum  hem- 
orrhage, 433 
Vomiting  in  pregnancy,  199 
Vulva,  49 

condition  of,  after  delivery,  556 

oedema  of,  obstructing  labor,  367 

vascular  supply  of,  53 
Vulvo-vaginal  glands,  53 

WAEBUEG'S  tincture,  627 
Weaning.     See  Laclalion. 
Wet-nurse,  selection  of,  566 

[diet  of,  567] 
Wolffian  bodies,  69,  121 
[Womanhood,  precocious  physical,  86] 
[Womb,  circular  contraction  of  the  middle 

of  the  (Blundell),  362] 
Wounds  of  the  foetus,  2^   ^,  , 

ZONA  pellucida,  78 
Zymotic  disease,   afiecting   the  fcetus, 
■  241      ■ 
as  a  cause  of  septicremia,  606 


t  \ 


THE    END 


2->e^ 


(l^^xZ^iv^ 


-■         »^/*v**'  L^^^-z**- 


1/^,^  V*'^^^  wX^tt^^-^-^— ^^'^/^ 


// 


V 


-'Crv-^ 


^■V 


^ 


LEA  BROTHERS  S  GO.'S 

CM 

f-  CLASSIFIED  CATALOGUE 

a> 

tMEDlCflL  AND  SURGICAL 

«  Piiblication0. 

1_  In  asking  tlie  attention  of  the  profession  to  the  works  advertised  in  the  following  pages, 

the  publishers  would  state  that  no  pains  are  spared  to  secure  a  continuance  of  the  confi- 
dence earned  for  the  publications  of  the  house  by  their  careful  selection  and  accuracy  and 
finish  of  execution. 

The  large  number  of  inquiries  received  from  the  profession  for  a  finer  class  of  bindings  than  is 
us/ually  placed  on  medical  books  has  induced  us  to  put  certain  of  our  standard  publications  in 
half  Russia;  and,  that  the  growing  taste  may  be  encouraged,  the  prices  have  been  fixed  at  so  small 
cm  advance  over  the  cost  of  sheep  as  to  place  it  within  the  means  of  all  to  possess  a  library  that 
shall  have  attractions  as  well  for  the  eye  as  for  the  mind  of  the  reading  practitioner. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works  not 
kept  in  stock.  Where  access  to  bookstores  is  not  convenient  books  will  be  sent  by  mail  by 
the  publishers  postpaid  on  receipt  of  the  printed  price,  and  as  the  limit  of  mailable  weight 
has  been  removed,  no  difficulty  will  be  experienced  in  obtaining  through  the  post-office 
any  work  in  this  catalogue.  No  risks,  however,  are  assumed  either  on  the  money  or  on 
the  books,  and  no  publications  but  our  own  are  supplied,  so  that  gentlemen  wiU  in  most 
cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

LEA   BROTHERS  &  CO. 

Nos.  706  and  708  Sansom  St.,  Phtladelphia,  September,  1889. 


Practical  Medical  Periodicals. 


g    THE  AMERICAN  JOURNAL  OF  THE  MEDICAL       ^  To  one  address. 

>»  SCIENCES,  Monthly,  $4.00  per  annum.  I  ^°^'^°J^' 

xs  I  ^  #  -  o  o 

«^    THE  MEDICAL  NEWS,  Weekly,  $5.00  per  annum,  j     per  annum. 

^    THE  MEDICAL  NEWS  VISITING  LIST  (3  styles,  see  p.  3),  $1.25. 
E  With  either  or  both  above  periodicals,  in  advance,  75c. 

%    THE  YEAR-BOOK   OF  TREATMENT  (see  p.  17),  $1.25.    With 

^  either  JOURNAL  or  NEWS,  or  both,  75c.    Or  JOURNAL, 

^  NEWS,  VISITING  LIST  and  YEAR-BOOK,  $8.50,  in  advance. 


WITH  1889,  The  Journal  enters  upon  its  sixty-ninth  and  The 
News  upon  its  forty-seventh  year.  Anticipating  the  require- 
ments of  the  times,  The  News  changed  from  a  monthly  journal  to  a 
vastly  larger  weekly  newspaper  in  1882,  and  The  Journal  changed  from 
a  quarterly  to  a  monthly  in  1888,  increasing  its  contents  and  simultaneously 
reducing  its  price.  Jointly  these  two  periodicals  combine  all  that  is  possible 
and  desirable  in  medical  journalism,  the  promptness  of  the  newspaper  and 
the  elaboration  of  the  magazine.  {Continued  on  next  page.) 


2    Lea  Brothers  &  Co.'s  Periodicals — Am.  Journal,  Medical  News. 

The  AgBrican  Jouiinal  and  T5b  ]?[ediGaI  fleW?. 

Continaed  from  First  Page. 

Great  care  is  exercised  to  make  them  thoroughly  practical  and  of  the 
utmost  possible  assistance  in  the  every-day  work  of  the  physician,  surgeon 
and  obstetrician.  The  Departments  of  Progress,  for  instance,  during 
1888,  contained  2300  individual  articles  on  Medical  Advances,  gathered 
from  the  medical  periodicals  of  the  world.  The  Original  Departments 
are  filled  with  important  communications  from  the  most  practical  minds  of 
the  profession  on  both  sides  of  the  Atlantic,  and  the  Reviews  convey 
impartial  judgments,  as  to  the  value  of  the  most  recent  additions  to  the 
literature  of  medicine.  In  addition  to  the  above  features  common  to  both. 
The  News  contains  carefully  gathered  details  of  advanced  Hospital  Treat- 
ment, skilful  Editorials  on  living  topics.  News  Items,  Society  Proceedings, 
Notes  and  Queries,  Correspondence,  etc. 

Designed  to  fill  distinct  and  complementary  spheres,  these  periodicals 
are  most  advantageously  read  in  conjunction,  and  to  lead  every  practi- 
tioner to  prove  this  for  himself  the  commutation  rate  has  been  placed 
at  the  very  low  figure  of  §7.50.  Their  cheapness  at  this  rate  is  rendered 
obvious  by  the  consideration  that  they  contain  most  valuable  matter, 
equivalent  to  9  octavo  volumes  of  700  pages'  each.  Although  fitted  to 
be  read  together,  each  periodical  is  individually  complete  and  contains 
no  duplicated  matter,  so  that  every  reader  of  either  is  kept  thoroughly 
posted.  The  reader  of  both  gains  the  grasp  of  medical  advance  which  is 
assured  by  locating  matters  from  difierent  points  of  view. 

As  a  premium  for  advance-payment  to  either  or  both  the  above 
periodicals.  The  Year-Book  of  Treatment  (see  page  17)  is  furnished  for 
75  cents  (regular  price,  ^1.25).  This  convenient  work  gives  an  inde- 
pendent and  classified  statement  of  the  value  and  uses  of  such  remedies 
as  have  been  introduced  and  tested  with  success  during  the  year. 

'-  Similarly,  The  Medical  News  Visiting  List,  the  most  perfect  work  of 
its  kind  (see  page  3),  is  furnished  to  advance-^Sbymg  subscribers  for  75 
cents  (regular  price,  $1.25).     Thumb-letter  index,  25  cents  extra. 

OR,    AS   A    SPECIAL   OFFER, 

JouKNAL,  News,  Year-Book  and  Visiting  List,  in  advance,  $8.50. 

Subscribers  can  obtain,  at  the  close  of  each  volume,  cloth  covers  for 
The  Journal  (one  annually),  and  for  The  News  (one  annually/),  free  by 
mail,  by  remitting  Ten  Cents  for  The  Journal  cover,  and  Fifteen  Cents 

/or  The  News  cover.  ""^  •■•'-''■-"- 

jl^^The  safest  mode  of  remittance  is  by  bank  check  or  postal  money 
order,  drawn  to  the  order  of  the  undersigned;  where  these  are  not  acces- 
sible, remittances  for  subscriptions  may  be  sent  at  the  risk  of  the  publishers 
by  forwarding  in  registered  letters.     Address, 

LEA  BROTHERS  &  CO.,  706  &  708  Sansom  Street,  Philadelphia. 


Lea  Brothers  &  Co.'s  Publications — Period.,  Manuals. 


THB  MEJJICAL  NEWS  VISITING  LIST  FOR  1800 

Has  been  revised  and  brouglit  thoroughly  uji  to  date  in  every  respect.  It  con- 
tains 48  pages  of  text,  inchiding  calendar  for  two  years;  obstetric  diagrams;  scheme 
of  dentition;  tables  of  weights  and  measures  and  comparative  scales;  instructions  for  ex- 
amining the  urine;  list  of  disinfectants;  table  of  eruptive  fevers;  lists  of  new  remedies 
and  remedies  not  generally  used ;  incompatibles,  poisons  and  antidotes;  artificial  resjiira- 
tion  ;  table  of  doses,  prepared  to  accord  with  the  last  revision  of  the  U.  S.  Pharmawpoeia ; 
an  extended  table  of  Diseases  and  their  remedies,  and  directions  for  ligation  of  ar^ 
teries.  176  pages  of  blanks  for  all  records  of  practice  and  erasable  tablet.  Handsomely 
bound  in  limp  Morocco,  with  pocket,  pencil,  rubber  and  catheter  scale. 

The  Medicai,  News  Visiting  List  for  1890  is  issued  in  three  styles,  as  heretofore : 
Weekly  (for  30  patients);  Monthly,  and  Perpetual.  Each  in  one  volume,  $1.25.  Also 
furnished  with  Keady  Eeference  Thumb-letter  Index  for  quick  use,  25  cents  extra.  For 
special  offers,  including  Visiting  List,  see  pages  1  and  2. 

A  few  notices  of  this  Visiting  List  are  appended  : 

eases  arranged  alphabetically,  giving  under  each 


This  list  is  all  that  could  be  desired.  It  con- 
tains a  vast  amount  of  useful  information,  especi- 
ally for  emergencies,  and  gives  good  table  of  doses 
and  therapeutics. — Canadian  Practitioner,  Jan.  '88. 

It  is  a  masterpiece.  Some  of  the  features  are 
peculiar  to  "The  Medical  News  Visiting  List," 
notably  the  Therapeutic  Table,  prepared  by  Dr.  T. 
Lauder  Brunton,  which  contains  the  list  of  dis- 


a  list  of  the  prominent  drugs  ernjiloyed  in  the 
treatment.  When  ordered,  a  Ready  Kef-rence 
Thumb-letter  Index  is  furnished.  This  is  a  feat- 
ure peculiar  to  this  Visiting  List. — Phynician  ami 
Surgeon,  December,  1887. 

For  convenience  and  elegance  it  is  not  surpasa- 
a^\ei.— Obstetric  Gazette,  November,  1887. 


TME  MEDICAL  NEWS  PHYSICIANS'  LEDGER, 

Containing  400  pages  of  fine  linen  "  ledger  "  paper,  ruled  so  that  all  the  accounts  of  a 
large  practice  may  be  conveniently  kept  in  it,  either  by  single  or  double  entry,  for  a  long 
period.  Strongly  bound  in  leather,  with  cloth  sides,  and  with  a  patent  flexible  back, 
which  permits  it  to  lie  perfectly  flat  when  opened  at  any  place.  Price,  $5.00.  Also, 
V  small  special  lot  of  same  Ledger,  with  300  pages.    Price,  $4.00. 


HARTSHORNE,  HENRY,  A,  M.,  M,  D.,  LL.  D., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania, 

A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  «iition,  thoroughly  revised  and  greatly  improved.  In  one  large  royal  12mo. 
volume  of  1028  pages,  with  477  illustrations.    Cloth,  |4.25 ;  leather,  $5.00. 


The  object  of  this  manual  is  to  afford  a  conven- 
ient work  of  reference  to  students  during  the  brief 
moments  at  their  command  while  in  attendance 
upon  medical  lectures.  It  is  a  favorable  sign  that 
it  has  been  found  necessary,  in  a  short  space  of 
time,  to  issue  a  new  and  carefully  revised  edition. 
The  illustrations  are  very  numerous  and  unusu 


industry  and  energy  of  its  able  editor. — Boston 
Medical  and  Surgical  Journal,  Sept.  3. 1874. 

We  can  say  with  the  strictest  truth  that  it  is  the 
best  work  of  the  kind  with  which  we  are  ac- 
quainted. It  embodies  in  a  condensed  form  all 
recent  contributions  to  practical  medicine,  and  is 
therefore  usefiil  to  everj' ousy  practitioner  through- 


ally  clear,  and  each  part  seems  to  have  received  out  our  country,  besides  being  admirably  adapted 
its  due  share  of  attention.  We  can  conceive  such  to  the  use  of  students  of  medicine.  The  book  is 
&  work  to  be  useful,  not  only  to  students,  but  to  faithfully  and  ably  executed.— C/iorJwtort  Medical 
practitioners  as  well.    It  reflects  credit  upon  the|  Journal,  Aphi,  1876. 


WEILL,  JOHN,  M,  H.,   and  SMITH,  F,  G,,  M,  D,, 

Late  Surgeon  to  the  Penna.  Hospital.  Prof,  of  the  Institutes  of  Med.  in  the  Univ.  of  Penna. 

An  Analytical  Compendium  of  the  Various  Branches  of  Medical 
Science,  for  the  use  and  examination  of  Students.  A  new  edition,  revised  and  imi)roved. 
In  one  large  royal  12mo.  volume  of  974  pages,  with  374  woodcuts.    Cloth,  $4;  leather,  $i4.75. 


LUDLOW,  J.L,,M,D., 

Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 

A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics,  lo  which 
is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised,  and  greatly  enlarged.  In 
one  12mo.  volume  of  816  pages,  with  370  illustrations.     Cloth,  $3.2o;  leather,  $3./o. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  espe- 
cially suitahle  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


4  Lea  Brothers  &  Co.'s  Publications — Dictionaries. 

BILLIJ^GS,  J.  S.,  A.  M.,  M,D,,  LL,D.,  Saw.  and  JEdin,, 

Membtr  National  Academy  of  Sciences,  Surgeon  U.  S.  A.,  etc. 
A  MEDICAL  DICTIONAEY,  including  in  one  alphabet  English,  French, 
German,   Italian  and  Latin    Technical  Terms  used  in   Medicine  and  the  Collateral 
Sciences,  with  accentuation  and  pronunciation  of  English  words.     By  JoHi;  S.  Bllungs, 
A.  M.,  M.  D.,  LL.  D. 

WITH  THE  COLLABORATION  OF 

W.  0.  ATWATER,  M.  D.,  WASHI^■G-TO^'  MATTHEWS,  M.D., 

FKAXK  BAKER,  M.  D.,  H.  C.  YARROW,  M.  D., 

JAMES  M.  FLI^"T,  M.  D.,  W.  T.  COO'CILMAN,  M.  D., 

R.  LORINI,  M.D.,  WILLIAM  LEE,  M.D., 

S.  M.  BURNETT,  M.  D.,  C.  S.  MIXOT,  M.D. 

J.  H.  EIDDER,  M.  D., 

In  two  very  handsome  royal  octavo  volumes. 

Shortly.    Subscription  only.    Address  the -Publishers. 


DimGLISOJ^,  ROBLBY,  M.D., 

Late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON ;  A  Dictionary  of  Medical  Science :  Containing 

a  concise  Explanation-of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  ZSTotices  of  Climate  and  of  ^Mineral  Waters,  Formulae  for  Officinal, 
Empirical  and  Dietetic  Preparations,  with  the  Accentuation  and  Etymology  of  the  Terms, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  Edited  by  Bickakd  J.  Dui^gusox,  M.D.  In  one  very  large  and 
handsome  royal  octavo  volume  of  1139  pages.  Cloth,  $6.50;  leather,  raised  bands,  $7.50; 
very  handsome  half  Eussia,  raised  bands,  $8. 


About  the  first  book  pnTcbased  by  the  medical 
Btudent  is  the  Medical  Dictionary.  The  lexicon 
explanatory  of  technical  terms  is  simply  a  sine  qua 
rum.  In  a  science  so  extensive  and  witn  such  col- 
laterals as  medicine,  it  is  as  much  a  necessity  also 
to  the  practising  physician.  To  meet  the  wants  of 
students  and  most  physicians  the  dictionary  must 
be  condensed  while  comprehensive,  and  prsictieal 
while  perspicacious.  It  was  because  Dunglison's 
met  these  indications  that  it  became  at  once  the 
dictionary  of  general  use  wherever  medicine  was 
studied  in  the  English  language.  In  no  former 
revision  have  the  alterations  and  additions  been 
so  great.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps; 
an  arrangement  which  greatly  facilitates  reference. 
— Cincinnati  Lancet  and  Clinic,  .Jan.  10, 1874:. 

A  book  of  which  every  American  ought  to  be 
proud.     When  the  learned  author  of  the  work 


passed  away,  probably  all  of  us  feared  lest  the  book 

c'hould  not  maintain  its  place  in  the  advancing 
science  whose  terms  it  defines.  Fortunately,  Dr. 
Richard  J.  Dunglison,  having  assisted  hisfatherin 
the  revision  of  several  editions  of  the  work,  and 
having  been,  therefore,  trained  in  the  methods 
and  imbued  with  the  spirit  of  the  book,  has  been 
able  to  edit  it  as  a  work  of  the  kind  should  be 
edited — to  carry  it  on  steadily,  without  jar  or  inter- 
ruption, along  the  grooves  of  thought  it  has  trav- 
elled during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and 
carried  through,  it  is  only  necessary  to  state  that 
more  than  six  thousand  new  subjects  have  been 
added  in  the  present  edition. — Philadelphia  Medical 
Times,  Jan.  3, 1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Gazette. 


MOBLYN,  niCWA  RD  JD.,  M.  D. 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  Collateral 
Sciences.  Revised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of  520 
double-columned  pages.    Cloth,  $1.50 ;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table. — Southern 
Medical  and  Surgical  Journal.  

STJJiyBN'TS'  SBBIBS  OF  MAJfUALS, 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine 
and  Surgery,  written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size 
12mo.  volumes  of  300-540  pages,  richly  illustrated  and  at  a  low  price.  The  following  vol- 
umes are  now  ready:  Teeves'  Manual  of  Surgery,  by  various  writers,  in  three  volumes, 
each",  $2 ;  Bell's  Comparative  Physiology  and  Anatomy,  $2 ;  Gould's  Surgical  Diagno- 
sis, %2;  EoBEETSOx's  Physiological  Physics,  $2;  'BnvCF^S  Materia  Med.ica  and  Therapeu- 
tics (4th  edition),  $1.50 ;  Powee's  Human  Physiology  (2d  edition),  $1.50 ;  Clakke  and 
Lockwood's  Dissector^  Manual,  $1.50;  Ealee's  Clinical  Chemistry,  $1.50;  Teevis' 
Surgical  Applied  Anato'my,  $2 ;  Pepper's  Surgical  Pathology,  $2 ;  and  Kleen's  Elements  of 
Histology  (4th  edition),  $1.75.  The  following  is  in  press :  Pepper's  Forensic  Medicine. 
For  separate  notices  see  index  on  last  page. 

8BBIBS  OF  CLINICAL  MANUALS. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the 
profession  with  a  collection  of  authoritative  monographs  on  important  clinical  subjects 
in  a  cheap  and  portable  form.  The  volumes  will  contain  about  550  pages  and  will  be 
freely  illustrated  by  chromo-lithographs  and  woodcuts.  The  following  volumes  are 
now  ready:  Caeteb  &  Feost's  Ophthalmic  Surgery,  $2.25;  HuTCHrNSON  on  Syphilis, 
$2.25 ;  Ball  on  the  Rectum  and  Anus,  $2.25 ;  Maesh  on  the  Joints,  $2 ;  Owen  on  Surgical 
Diseases  of  Children,  $2 ;  Moeeis  on  Surgical  Diseases  of  the  Kidney,  $2.25 ;  Pick  on 
Fractures  and  Dislocations,  $2 ;  BtrrLDf  on  the  Tongue,  $3.50 ;  Treves  on  Intestirwl 
Obstruction,  $2 ;  and  Savage  on  Insanity  a-nd  Allied  Neuroses,  $2.  The  following  are  in 
active  preparation:  Beoadbent  on  the  Pulse,  and  Lucas  on  Diseases  of  the  Urethra. 
For  separate  notices  see  index  on  last  page. 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


GMAY,  HENJRY,  F.  M.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

J  ■^^^t^'^^'  ^descriptive  and  Surgical.  The  Drawings  by  H.  V.  Carter,  M.  D., 
and  Dr.  Westmacott.  The  dissections  jointly  by  the  Author  and  Dr.  Carter.  With 
an  Introduction  on  General  Anatomy  and  Development  by  T.  Holmes  M  A  Surgeon  lo 
St.  George's  Hospital.  Edited  by  T.  Pickering  Pick,  F.  R.  C.  S.,  Surgeon  to  and  Lecturer 
on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy,  Roval  College  of 
Surgeons  of  England.  A  new  American  from  the  eleventh  enlarged  and  improved  London 
edition,  thoroughly  revised  and  re-edited  by  William  W.  Keen,  M.  D.,  Professor  of 
Anatomy  in  the  Pennsylvania  Academy  of  the  Fine  Arts,  etc.  To  which  is  added  the 
Becond  American  from  the  latest  English  edition  of  Landmarks,  Medical  and  Surgi- 
cal, by_  Luther  Holden,  F.  E.  C.  S.  In  one  imperial  octavo  volume  of  1098 
pages,  with  685  large  and  elaborate  engravings  on  wood.  Price  of  edition  in  black : 
Cloth,  $6 ;  leather,  $7 ;  half  Russia,  $7.50.  Price  of  edition  in  colors  (see  below)  : 
Cloth,  $7.25;  leather,  $8.25;  half  Russia,  $8.75. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  In  this  edition  a  new  departure 
has  been  taken  by  the  issue  of  the  work  with  the  arteries,  veins  and  nerves  distinguished 
by  different  colors.  The  engravings  thus  form  a  complete  and  splendid  series,  which  will 
greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recall- 
ing the  details  of  the  dissecting-room.  '  Combining,  as  it  does,  a  complete  Atlas  of 
Anatomy  with  a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy, 
the  work  will  be  found  of  great  service  to  all  physicians  who  receive  students  in  their 
offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the  groundwork  of  a 
thorough  medical  education. 

For  the  convenience  of  those  who  prefer  not  to  pay  the  slight  increase  in  cost  necessi- 
tated by  the  use  of  colors,  the  volume  is  published  also  in  black  alone,  and  maintained 
in  this  style  at  the  price  of  former  editions,  notwithstanding  the  largely  increased  size  of 
the  work. 

Landmarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study. 


The  most  popular  work  on  anatomy  ever  written. 
It  is  sufficient  to  say  of  it  that  this  edition,  thanks 
to  its  American  editor,  surpasses  all  other  edi- 
tions.— Jour,  of  the  Amer.  Med.  Ass'n,  Dec.  31, 1887. 

A  work  which  for  more  than  twenty  years  has 
had  the  lead  of  all  other  text-books  on  anatomy 
throughout  the  civilized  world  comes  to  hand  in 
such  beauty  of  execution  and  accuracy  of  text 
and  illustration  as  more  than  to  make  good  the 
large  promise  of  the  prospectus.  It  would  be  in- 
deed difficult  to  name  a  feature  wherein  the  pres- 
ent American  edition  of  Gray  could  be  mended 
or  bettered,  and  it  needs  no  prophet  to  see  that 
the  royal  work  is  destined  for  many  years  to  come 
to  hold  the  first  place  among  anatomical  text- 


books. The  work  is  published  with  black  and 
colored  plates.  It  is  a  marvel  of  book-making. — 
American  Practitioner  and  News,  Jan.  21, 1888. 

Gray's  Anatomy  is  the  most  magnificent  work 
upon  anatomy  which  has  ever  been  published  in 
the  English  or  any  other  language.— Ci'/icinnafi 
Medical  News,  Nov.  1887. 

As  the  book  now  goes  to  the  purchaser  he  is  re- 
ceiving the  best  work  on  anatomy  that  is  published 
in  any  language. —  Virginia  Med.  Monthly,  Dec.  1887. 

Gray's  standard  Anatorny  has  been  and  will  be 
for  years  the  text-book  for  students.  The  book 
needs  only  to  be  examined  to  be  perfectly  under- 
stood.— Medical  Fress  of  Western  New  York,  Jan. 
1888. 


Also  for  sale  separate — 
MOLJyFN,  LJJTMBMf  F,  M,  C,  S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals,  London. 

Landmarks,  Medical  and  Surgical.  Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomv  in 
the  Pennsylvania  Academy  of  the  Fine  Arts,  formerly  Lecturer  on  Anatomy  in  the  Phila- 
delphia School  of  Anatomy.    In  one  handsome  12mo.  volume  of  148  pages.    Cloth,  $1.00. 

This  little  book  is  all  that  can  be  desired  within 
its  scope,  and  its  contents  will  be  found  simply  in- 
valuable to  the  young  surgeon  or  physician,  since 
they  bring  before  him  such  data  as  he  requires  at 
every  examination  of  a  patient.  It  is  written  in 
language  so  clear  and  concise  that  one  ought 
almost  to  learn  it  by  heart.  It  teaches  diagnosis  by 
external  examination,  ocular  and  palpable,  of  the 
body,  with  such  anatomical  and  physiological  facts 
as  directly  bear  on  the  subject.  It  is  eminently 
the  student's  and  young  practitioner's  book.— /'Aj/- 
sician  and  Surgeon,  Nov.  1881.  ,_...• 

The  study  of  these  Landmarks  by  both  physi- 


cians and  surgeons  is  much  to  be  encouraged.  It 
inevitably  leads  to  a  progressive  education  of  both 
the  eye  and  the  touch,  by  which  the  recognition  of 
disease  or  the  localization  of  injuries  is  vastly  as- 
sisted. One  thoroughly  familiar  with  the  facts  here 
taught  is  capable  of  a  degree  of  accuracy  and  a 
confidence  of  certainty  which  is  otherwise  unat- 
tainable. We  cordially  recommend  the  Landmarks 
to  the  attention  of  ever.v  physician  who  has  not 
yet  provided  himself  with  a  copy  of  this  useful, 
practical  giride  to  the  correct  placing  of  all  the 
anatomical  parts  and  orgims,— Canada  Medical  and 
Surgical  Journal,  Dec.  1881. 


6 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


ALLBN,  HARBISON,  M,  !>., 

Profesfior  of  Physiology  in  the  University  of  Pennsylvania, 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  With  an  Intro- 
ductory Section  on  Histology.  By  E.  O.  Shakespf.ake,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Section  I.  Histology. 
Section  II.  Bones  and  Joints.  Section  HI.  Muscles  and  Fascia.  Section  IV. 
Artekies,  Veins  and  Lymphatics.  Section  V.  Nebvous  System.  Section  VI. 
Organs  of  Sense,  of  Digestion  and  Genito-Urinary  Organs,  Embryology, 
Development,  Teratology,  Superficial  Anatomy,  Post-Mortem  Examinations, 
AND  General  and  Clinical  Indexes.  Price  per  Section,  $3.50 ;  also  bound  in  one 
volume,  cloth,  $23.00 ;  very  handsome  half  Russia,  raised  bands  and  open  back,  $25.00. 
For  sale  by  subscription  only.     Apply  to  the  Pvhlishers. 


It  is  to  oe  considered  a  study  of  applied  anatomy 
In  its  widest  sense — a  systematic  presentation  of 
such  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgeiy.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 
sidered a  dry  subject.  The  department  of  Histol- 
ogy is  treated  in  a  masterly  manner,  and  the 
ground  is  travelled  over  by  one  thoroughly  famil- 
iar with  it.    The  illustrations  are  made  with  great 


care,  and  are  simply  superb.  There  is  as  much 
of  practical  application  of  anatomical  points  to 
the  every-day  wants  of  the  medical  clinician  as 
to  those  of  tne  operating  surgeon.  In  fact,  few 
general  practitioners  will  read  the  work  without  a 
feeling  of  surprised  gratification  that  so  many 
points,  concerning  which  they  may  never  have 
thought  before  are  so  well  presented  for  their  con- 
sideration. It  is  a  work  which  is  destmed  to  be 
the  best  of  its  kind  in  any  language. — Medical 
Record,  Nov.  25, 1882. 


CLAMKB,  W.  B,,  F,B,  C.S.  &  LOCKWOOI>, C.  B,,  F,B,  C.S, 

Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical  School,  London. 
The  Dissector's  Manual.     In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49  illustrations.    Limp  cloth,  red  edges,  $1.50.     See  Students'  Series  of  Manuals,  page  4. 


Messrs. Clarke  and  Lockwood  have  written  a  book 
that  can  hardly  be  rivalled  as  a  practical  aid  to  the 
dissector.  Their  purpose,  whicn  is  "  how  to  de- 
scribe the  best  way  to  display  the  anatomical 
structure,"  has  been  fully  attained.  They  excel  in 
a  lucidity  of  demonstration  and  graphic  terseness 
of  expression,  which  only  a  long  training  and 


intimate  association  with  students  could  have 
given.  With  such  a  guide  as  this,  accompanied 
by  so  attractive  a  commentary  as  Treves'  Surgical 
Applied  Anatomy  (same  series),  no  student  could 
fail  to  be  deeply  and  absorbingly  interested  in  the 
study  of  anatomy. — New  Orleans  Medical  a»cj  >Siw- 
gieal  Journal,  April,  1884. 


TBEVES,  FBEI>BBICK,  F,  B,  C,  S., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  SospitaL 
Surgical  Applied  Anatomy.     In  one  pocket-size  12mo.  volume  of  540  pages, 
with   61   illustrations.   Limp  cloth,  red  edges,  $2.00.    See  Students'  Series  of  Manuals, 
page  4. 


He  has  produced  a  work  which  will  command  a 
larger  circle  of  readers  than  the  class  for  which  it 
was  written.  This  union  of  a  thorough,  practical 
acquaintance  with  these  fundamental  branches, 
quickened  by  daily  use  as  a  teacher  and  practi- 
tioner, has  enabled  our  author  to  prepare  a  work 
which  it  would  be  a  most  difficult  task  to  excel. — 
The  American  Practitioner,  Feb.  1884. 


This  number  of  the  "  Manuals  for  Students  "  is 
most  excellent,  giving  just  such  practical  knowl- 
edge as  will  be  requiredforapplication  in  relieving 
the  injuries  to  which  the  living  body  is  liable. 
The  book  is  intended  mainly  for  students,  but  it 
will  also  be  ofgreat  use  to  practitioners.  The  illus- 
trations are  well  executed  and  fully  elucidate  the 
text. — Southern  Practitioner,  Feb.  1884. 


BFLLA3IT,  FDWABD,  F.  B.  C,  S., 

Senior  Assistant-Surgeon  to  the  Charing-Oross  Hospital,  London, 

The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  Important  Surgical  Regions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
operative  vSurgery.    In  one  12mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2.25. 

WILSON,  FBASMUS,  F.  B.  S, 

A  System  of  Human  Anatomy,  General  and  Special.  Edited  by  VV,  H. 
Gobrecht,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  ol 
Ohio.  In  one  large  atid  handsome  octavo  volume  of  616  pages,  with  397  illustrations. 
Cloth,  $4.00 ;  leather,  $5.00. " 

CLMIjAND,  JOHN,  M,  D.,  F,  B.  S., 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Qaiway, 

A  Directory  for  the  Dissection  of  the  Human  Body.     In  one  12mo. 

volume  of  178  pages.     Cloth,  $1.25. 


hartshorne's  handbook  of  anatomy 

and  physiology.  Second  edition,  revised. 
In  one  royal  12mo.  volume  of  310  pages,  with  220 
woodcuts.    Cloth,  81.75. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  two  octavo  volumes  of  1007  pages, 
with  320  woodcuts.    Cloth,  86.00. 


Xea  Brothers  &  Co.'s  Publications — Physics,  I^hySioi.,Atiat.        t 


I>RAPJEM,  JOMJSr  a,  M,  JD.,  LL,  D., 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 
Medical  Physics.     A  Text-book  for  Students  and  Practitioners  of  Medicine.    In 
one  octavo  volume  of  734  pages,  with  376  woodcuts,  mostly  original.    Cloth,  $4. 

FROM  THE  PREFACE. 

The  fact  that  a  knowledge  of  Physics  is  indispensable  to  a  thorough  understanding  of 
Medicine  has  not  been  as  fully  realized  in  this  country  as  in  Europe,  where  the  admiraljle 
works  of  Desplats  and  Gariel,  of  Kobertson  and  of  numerous  German  writers  constitute  a 
branch  of  educational  literature  to  which  we  can  show  no  parallel.  A  full  appreciation 
of  this  the  author  trusts  will  be  sufficient  justification  for  placing  in  book  form  the  sub- 
stance of  his  lectures  on  this  department  of  science,  delivered  during  many  years  at  the 
University  of  the  City  of  New  York. 

Broadly  speaking,  this  work  aims  to  impart  a  knowledge  of  the  relations  existing 
between  Physics  and  Medicine  in  their  latest  state  of  development,  and  to  embody  in  the 
pursuit  of  this  object  whatever  experience  the  author  has  gained  during  a  long  period  of 
teaching  this  special  branch  of  applied  science. 


This  elegant  and  useful  work  bears  ample  testi- 
mony to  the  learning  and  good  judgment  of  the 
author.  He  has  fitted  his  work  admirably  to  the 
exigencies  of  the  situation  by  presenting  the 
reader  with  brief,  clear  and  simple  statements  of 
such  propositions  as  he  is  by  necessity  required  to 
master.  The  subject  matter  is  well  arranged, 
liberally  illustrated  and  carefully  indexed.  That 
it  will  take  rank  at  once  among  the  text-books  is 

•  certain,  and  it  is  to  be  hoped  that  it  will  find  a 
place  upon  the  shelf  of  the  practical  physician, 
where,  as  a  book  of  reference,  it  will  be  found 
useful  and    agreeable. — Louisville   Medical   News, 

■■  September  26, 1885. 

Certainly  we  have  no  text-book  as  full  as  the  ex- 
cellent one  he  has  prepared.  It  begins  with  a 
statement  of  the  properties  of  matter  and  energy. 
After  these  the  special  departments  of  physics  are 


explained,  acoustics,  optics,  heat,  electricity  and 
magnetism,  closing  with  a  section  on  electro- 
biology.  The  applications  of  all  these  to  physiology 
and  medicine  are  kept  constantly  in  view.  The 
text  is  amply  illustrated  and  the  many  difficult 
points  of  the  subject  are  brought  forward  with  re- 
markable clearness  and  ability. — Medical  and  Surg- 
ical Reporter,  July  18,  1885. 

That  this  work  will  greatly  faalUtate  the  study 
of  medical  physics  is  apparent  upon  even  a  mere 
cursory  examination.  It  is  marked  by  that  scien- 
tific accuracy  which  always  characterizes  Dt. 
Draper's  writings.  Its  peculiar  value  lies  in  the 
fact  that  it  is  written  from  the  standpoint  of  the 
medical  man.  Hence  much  is  omitted  that  ap- 
pears in  a  mere  treatise  on  physical  science,  while 
much  is  inserted  of  peculiar  value  to  the  physi- 
cian.— Medical  Record,  August  22, 1885. 


BOBBBTSOW,  J,  McGMEGOM,  M.  A.,  M,  B,, 

Muirhead  Demonstrator  of  Physiology,  University  of  Olasgow. 
Physiological  Physics.     In  one  12mo.  volume  of  537  pages,  with  219  illustre 
"tions.     Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  4. 

The  title  of  this  work  sufficiently  explains  the 
nature  of  its  contents.  It  is  designed  as  a  man- 
ual for  the  student  of  medicine,  an  auxiliary  to 
his  text-book  in  physiology,  and  it  would  be  particu- 
Jarly  useful  as  a  guide  to  his  laboratory  experi- 


ments. It  will  be  found  of  great  value  to  the 
practitioner.  It  is  a  carefully  prepared  book  of 
reference,  concise  and  accurate,  and  aa  such  we 
heartily  recommend  it. — Journal  of  the  American 
Medical  Association,  Dec.  6, 1884. 


DALTON,  JOHW  C,  M,  !>., 

Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  ond  Swgeons,  New  York. 

Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physiological 
•Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  In  one  handsome 
12mo.  volume  of  293  pages.     Cloth,  $2. 


Dr.  Dal  ton's  work  is  the  fruit  of  the  deep  research 

■  of  a  cultured  mind,  and  to  the  busy  practitioner  it 
-cannot  fail  to  be  a  source  of  instruction.    It  will 

inspire  him  with  a  feeling  of  gratitude  and  admir- 
ation for  those  plodding  workers  of  olden  times, 

■  who  laid  the  foundation  of  the  magnificent  temple 
of  medical  science  aa  it  now  stands. — New  Orleans 
Medical  and  Surgical  Journal,  Aug.  1885. 

In  the  progress  of  physiological  study  no  fact 
"Was  of  greater  moment,  none  more  completely 


revolutionized  the  theories  of  teachers,  than  the 
discovery  of  the  circulation  of  the  blood.  This 
explains  the  extraordinary  interest  it  has  to  all 
medical  historians.  The  volume  before  us  is  one 
of  three  or  four  which  have  been  written  within  a 
few  years  by  American  physicians.  It  is  in  several 
respects  the  most  complete.  The  volume,  though 
small  in  size,  is  one  of  the  most  creditable  con- 
tributions from  an  American  pen  to  medical  history 
that  has  appeared.— Med.  £  Surg.  Rep.,  Dec.  6, 1884. 


BMLL,  F,  JEFFMEY,  M.  A., 

Professor  of  Comparative  Anatomy  at  King's  College,  London. 

Comparative  Physiology  and  Anatomy.  In  one  12mo.  volume  of  561  pages, 
'with  229  illustrations.  Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  4. 

The  manual  is  preeminently  a  student's  book— I  it  the  best  work  in  existence  in  the  English 
■  clear  and  simple  in  language  and  arrangement,  language  to  place  in  the  hands  of  the  medictil 
It  is  well  and  abundantly  illustrated,  and  is  read-  student.— ^ristoi  Medico- ClUrurgical  Journal,  ilar. 
,»ble  and  interesting.    On  the  whole  we  consider  |  1886. 

ELLIS,  GEORGE  VINEB, 

Emeritus  Professor  of  Anatomy  in  University  College,  London. 
Demonstrations    of   Anatomy.      Being  a  Guide  to  the  Knowledge   of   the 
Human  Body  by  Dissection.     From  the  eighth  and  revised  London  edition.     In  one  very 
:handsome  octavo  volume  of  716  pages,  with  249  illustrations.    Cloth,  $4.25 ;  leather,  $5.25. 

MOBEMTS,  JOH]^  B,,  A,  M.,  M.  L>., 

Prof,  of  Applied  Anat.  and  Oper.  Surg,  in  Phila.  Polyclinic  and  Coll.  for  Oraduates  in  Medicine. 
The  Compend  of  Anatomy.     For  use  in  the  dissecting-room  and  in  preparing 
for  examinations.     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  75  cents. 


8        Lea  Brothers  &  Co.'s  Publications — Physiology,  Cliemistry. 


CHAPMAN,  SBNBT  C,  M.  D,, 

Professor  of  Institutes  of  Medicine  and  Medical  Juris,  in  the  Jefferson  Med.  Coll.  of  Philadelphia. 

A  Treatise  on  Human  Physiology.     In  one  handsome  octavo  volume  of 
925  pages,  with  605  fine  engravings.     Cloth,  $5.50 ;  leather,  |6.50. 

farther,  and  the  latter  will  find  entertainment  and 
instruction  in  an  admirable  book  of  reference. — 
North  Carolina  Medical  Journal,  Nov.  1887. 


It  represents  very  fully  the  existing  state  of 
physiology.  The  present  work  has  a  special  value 
to  the  student  and  practitioner  as  devoted  more 
to  the  practical  application  of  well-known  truths 
which  the  advance  of  science  has  given  to  the 
profession  in  this  department,  which  may  be  con- 
sidered the  foundation  of  rational  medicine.— .Bm/- 
falo  Medical  and  Surgical  Journal,  Dec.  1887. 

Matters  which  have  a  practical  bearing  on  the 
practice  of  medicine  are  lucidly  expressed;  tech- 
nical matters  are  given  in  minute  detail ;  elabo- 
rate directions  are  stated  for  the  guidance  of  stu- 
dents in  the  laboratory.  In  every  respect  the 
work  fulfils  its  promise,  whether  as  a  complete 
treatise  for  the  student  or  for  the  physician ;  for 
the  former  it  is  so  complete  that  he  need  look  no 


The  work  certainly  commends  itself  to  both 
student  and  practitioner.  What  is  most  demanded 
by  the  progressive  physician  of  to-day  is  an  adap- 
tation of  physiology  to  practical  therapeutics,  and 
this  work  is  a  decided  improvement  in  this  respect 
over  other  works  in  the  market.  It  will  certainly 
take  place  among  the  most  valuable  text-books. — 
Medical  Age,  Nov.  25, 1887. 

It  is  the  production  of  an  author  delighted  with 
his  work,  and  able  to  inspire  students  with  an  en- 
thusiasm akin  to  his  own. — American  Practitioner 
and  News,  Nov.  12, 1887. 


DAZTON,  JOHN  a,  M.  JO,, 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc.  « 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.  Seventh  edition,  thoroughly  revised  and  rewritten.  In  one 
very  handsome  octavo  volmne  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
$5.00;  leather,  |6.00. 

Frona  the  first  appearance  of  the  book  it  has 
been  a  favorite,  owing  as  well  to  the  author's 
renown  as  an  oral  teacher  as  to  the  charm  of 
simplicity  with  which,  as  a  writer,  he  always 
succeeds  in  investing  even  intricate  subjects. 
It  must  be  gratifying  to  him  to  observe  the  fre- 
quency with  which  his  work,  written  for  students 
and  practitioners,  is  quoted  by  other  writers  on 
physiology.  This  fact  attests  its  value,  and,  in 
great  measure,  its  originality.  It  now  needs  no 
such  seal  of  approbation,  however,  for  the  thou- 
sands who  have  studied  it  in  its  various  editions 


have  never  been  in  any  doubt  as  to  its  sterling 
worth.— iV.  T.  Medical  Journal,  Oct.  1882. 

Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 
which  it  could  be  reviewed  in  the  ordinary  sense. 
The  work  is  eminently  one  for  the  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 
of  physiology  which  have  a  direct  bearing  on  the 
diagnosis  and  treatment  of  disease.  The  work  is 
one  which  we  can  highly  recommend  to  all  our 
readers. — Dublin  Journal  of  Medical  Science,  Feb.'SS. 


FOSTJEM,  MICHAEL,  M,  D.,  F,  M,  S,, 

Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England. 
Text-Book  of  Physiology.     New  (fourth)  American  from  the  fifth  and  revised 
English  edition,  with  notes  and  additions  by  E.  T.  Eeicheet,  M.  D.,  Professor  of  Physi- 
ology in  University  of  Pennsylvania.     Preparing. 

A  REVIEW  OF   THE  FIFTH  ENGLISH  EDITION  IS  APPENDED. 


It  is  delightful  to  meet  a  book  which  deserves 
only  unqualified  praise.  Such  a  book  is  now  before 
us.  It  is  in  all  respects  an  ideal  text'book.  With  a 
complete,  accurate  and  detailed  knowledge  of  his 
subject,  the  author  has  succeeded  in  giving  a 
thoroughly  consecutive  and  philosophic  account 
of  the  science.  A  student's  attention  is  kept 
throughout  fixed  on  the  great  and  salient  ques- 


tions, and  his  energies  are  not  frittered  away  and 
degenerated  on  petty  and  trivial  details.  Review- 
ing this  volume  as  a  whole  we  are  justified  in  say- 
ing that  it  is  the  only  thoroughly  good  text-book 
of  physiology  in  the  English  language,  and  that  it 
is  probably  the  best  text-book  in  any  language. 
—Edinburgh  Medical  Journal,  December  1888. 


FOWFB,  HENMY,  M.  B,,  F,  M,  C.  S., 

Examiner  in  Physiology,  Royal  College  of  Surgeons  of  England. 
Human  Physiology.     Second  edition.    In  one  handsome  pocket-size  12mo.  vol- 
ume of  396  pp.,  with  47  illustrations.     Cloth,  $1.50.    See  Students'  Series  of  Manuals,  p.  4. 

SIMON,  W.,  Fh,  D,,  M.  D., 

Professor  of  Chemistry  and  Toxicology  in  the  College  of  Physicians  and  Surgeons,  Baltimore,  and 

Professor  of  Chemistry  m  the  Maryland  College  of  Pharmacy. 
Manual  of  Chemistry.   A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.    A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
New  (second)  edition.    In  one  8vo.  vol.  of  478  pp.,  with  44  woodcuts  and  7  colored  plates 
illustrating  56  of  the  most  important  chemical  tests.     Just  ready.    Cloth,  $3.25. 

FROM  THE  PREFACE. 
It  has  been  the  aim  of  the  Author  to  present  a  work  on  general  chemistry  which  may  be  used  to 
advantage  as  a  text-book  by  beginners,  and  which,  at  the  same  time,  covers  the  special  needs  of  the 
medical  and  pharmaceutical  student.  While  the  general  character  of  the  second  edition  is  the  same 
as  that  of  the  first,  many  changes  and  numerous  additions  have  been  made  with  the  view  of  render- 
ing the  work  more  complete  and  useful.  For  the  special  benefit  of  pharmaceutical  and  medical  stu- 
dents all  chemicals  mentioned  in  the  United  States  Pharmacopoeia  are  included,  and  when  of  sufficient 
interest,  are  fully  considered.  Having  frequently  noticed  the  difficulty  experienced  by  beginners  in 
becoming  familiar  with  the  variously  shaded  colors  of  chemicals  and  their  reactions,  the  Author 
decided  to  illustrate  the  work  with  a  number  of  plates,  presenting  the  colors  of  those  most  important 

Wohler's  Outlines  of  Organic  Chemistry.    Edited  by  Fittig.    Translated 
by  Ira  Eemsen,  M.  T>.,  Ph.  D.    In  one  12mo.  volume  of  550  pages.    Cloth,  $3. 
LEHM  ANN'S  MANUAL  OP  CHEMICAL  PHYS-  I  CARPENTER'S  PRIZE  ESSAY  ON  THE  USB  AND 

lOLOGrY.    In  one  octavo  volume  of  327  pages,  1     Abtoe  of  Alcoholic  Liqttoes  in  Health  and  Dis- 
CARPENTORt  HUMAN  PHySoLOGY.    Edited       ^^«=-  With  explanations  of  scientific  words.  Small 

by  Henby  Powee.    In  one  octavo  volume.  1     12mo.    178  pages.    Cloth,  60  cents. 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


FBANKLAND, E.,  J>.  C.  L,,  F.B.S,,  &JAI*I>,  F,  M.,  F, I,  C, 


Professor  of  Chemistry  in  the  Normal  School 
of  Science,  London. 


Assist.  Prof,  of  Chemistry  in  the  Normal 
School  of  Science,  London. 


Inorganic  Chemistry.    In  one  handsome  octavo  volume  of  677  pages  with  51 
woodcuts  and  2  plates.     Cloth,  $3.75 ;  leather,  $4.75. 

This  work  should  supersede  other  works  of  its 
class  in  the  medical  colleges.  It  is  certainly  better 
adapted  than  any  work  upon  chemistry,with  which 
we  are  acquainted,  to  impart  that  clear  and  full 
knowledge  of  the  science  which  students  of  med- 
icine should  have.  Physicians  who  feel  that  their 
chemical  knowledge  is  behind  the  times,  would 
do  well  to  devote  some  of  their  leisure  time  to  the 
study  of  this  work.  The  descriptions  and  demon- 
strations are  made  so  plain  that  there  is  no  diffi- 
culty in  understanding  them.— Cincinnati  Medical 
News,  January,  1886. 


This  excellent  treatise  will  not  fail  to  take  Its 
place  as  one  of  the  very  best  on  the  subject  of 
which  it  treats.  We  have  been  much  pleased 
with  the  comprehensive  and  lucid  manner  In 
which  the  difficulties  of  chemical  notation  and 
nomenclature  have  been  cleared  up  by  the  writers. 
It  shows  on  every  page  that  the  problem  of 
rendering  the  obscuritfes  of  this  science  easy 
of  comprehension  has  long  and  successfully 
engaged  the  attention  of  the  Anthoia,— Medical 
and  Surgical  Beporter,  October  31, 1885. 


FOWNES,  GEOMGE,  I*h.  J>. 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Em- 
bodying Watts'  Physical  Inorganic  Chemistry.  New  American,  from  the  twelfth  English 
edition.  In  one  large  royal  12mo.  volume  of  1061  pages,  with  168  illustrations  on  wood 
and  a  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 

Fownes^  Chemistry  has  been  a  standard  text- 
book upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 


everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.  It  has  steadily 
maintained  its  position  as  a  text-book  with  medi- 
cal students.  In  this  work  are  treated  fully:  Heat, 
Light  and  Electricity,  including  Magnetism.  The 
influence  exerted  by  these  forces  in  chemical 
action  upon  health  and  disease,  etc.,  is  of  the  most 
important  kind,  and  should  be  familiar  to  every 
medical  practitioner.  We  can  commend  the 
work  as  one  of  the   very  best  text-books    upon 


chemistry  extant. — Cincinnati  Medical  News,  Oc- 
tober, 1885. 

Of  all  the  works  on  chemistry  intended  for  the 
use  of  medical  students,  Fownes'  Chemistry  is 
perhaps  the  most  widely  used.  Its  popularity  is 
based  upon  its  excellence.  This  last  edition  con- 
tains all  of  the  material  found  in  the  previous, 
and  ijt  is  also  enriched  by  the  addition  of  Watts' 
Physical  and  Inorganic  Chemistry.  All  of  the  mat- 
ter is  brought  to  the  present  standpoint  of  chemi- 
cal knowledge.  We  may  safely  predict  for  this 
work  a  continuance  of  the  fame  and  favor  it  enjoys 
among  medical  students. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1886. 


ATTFIELD,  JOSN,  FJi,  D., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Oreat  Britain,  etc 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  twelfth 
English  edition,  specially  revised  by  the  Author  for  America.  In  one  handsome  royal 
12mo.  volume  of  about  750  pages,  with  about  100  illustrations.    In  press. 

A  notice  of  the  previous  edition  is  appended. 


It  is  a  book  on  which  too  much  praise  cannot  be 
bestowed.  As  a  text-book  for  medical  schools  it 
is  unsurpassable  in  the  present  state  of  chemical 
science,  and  having  been  prepared  with  a  special 
view  towards  medicine  and  pharmacy,  it  is  alike 
Indispensable  to  all  persons  engaged  in  those  de- 
partments of  science.  It  includes  the  whole 
chemistry  of  thelast  Pharmacopoeia. — Pacific  Medi- 
cal and  Surgical  Journal,  Jan.  1884. 

A  text-book  which  passes  through  ten  editions 


in  sixteen  years  must  have  good  qualities.  It 
seems  desirable  to  point  out  that  feature  of  the 
book  which,  in  all  probability,  has  made  it  so 
popular.  There  can  be  little  doubt  that  it  is  its 
thoroughly  practical  character,  the  expression 
being  used  in  its  best  sense.  The  author  under- 
stands what  the  student  ought  to  learn,  and  is  able 
to  put  himself  in  the  student's  place  and  to  appre- 
ciate his  state  of  miud.— American  Chemical  Jour- 
nal, April,  1884. 


BLOXAM,  CMABLES  L,, 

Professor  of  Chemistry  in  King's  College,  London. 

Chemistry,  Inorganic  and  Organic.  New  American  from  the  fifth  Lon- 
don edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.    Cloth,  $2.00 ;  leather,  $3.00, 

Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  diflfers  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypotheses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 
quence that  the  student  never  has  occasion  to 
complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  to  experimental  illustrations  ol 
chemical  principles  and  phenomena,  and  the 
mode  of  conducting  these  experiments.  The  book 
maintains  the  position  it  has  always  held  as  one  ol 


the  best  manuals  of  general  chemistry  hi  the  Eng- 
lish language. — Detroit  Lancet,  Feb.  1884. 

We  know  of  no  treatise  on  chemistry  which 
contains  so  much  practical  information  in  the 
same  number  of  pages.  The  book  can  be  readily 
adapted  not  only  to  the  needs  of  those  who  desire 
a  tolerably  complete  course  of  chemistry,  but  also 
to  the  needs  of  those  who  desire  only  a  general 
knowledge  of  the  subject.  We  take  pleasure  in 
recommending  this  work  both  as  a  satisfactory 
text-book,  and  as  a  useful  book  of  reference.— £og- 
ton  Medical  and  Surgical  Journal,  Juoe  19, 18S4. 


GBEEWE,  WILLIAM  S,,  M,  JD., 

Demonstrator  of  Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania. 

A  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  Based  upon  Bow. 
man's  Medical  Chemistry.  In  one  12mo.  volume  of  310  pages,  with  /4  lUus.  Cloth,  $1.75: 
It  is  a  concise  manual  of  three  hundred  pages,  I  the  recognition  of  compounds  due  to  pathological 
sivine  an  eSlent  summary  of  the  best  methods  conditions.  The  detection  of  poisons  is  treated 
If  SziSXuidrandiolidsofthebody,both  with  sufficient  fulness  for  the  purpose  of  thesta- 
for  ttierstSiWof  their  normal  constituents  and    dent  or  practitioner.-Boston  Jl.  of  Chem.  June.'SO. 


10 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


BEMSBN,  IRA,  M.  D.,  I^h.  J>., 

Professor  of  Chemistry  in  the  Johns  Hopkins  University,  Baltimore. 
Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.    New  (third)  and  thoroughly  revised  edition.    In  one  hand- 
some royal  12mo.  volume  of  316   pages.     Cloth,  |2.00 

This  work  of  Dr.  Remsen  is  the  yery  textbook 
needed,  and -the  medical  student  who  has  it  at 
his  fingers'  ends,  so  to  speak,  can,  if  he  chooses. 


make  himself  familiar  with  any  branch  of  chem- 
istry which  he  may  desire  to  pursue.  It  would  be 
difficult  indeed  to  find  a  more  lucid,  full,  and  at 
the  same  time  compact  explication  of  the  philos- 
ophy of  chemistry,  than  the  book  before  us,  and 
we  recommend  it  to  the  careful  and  impartial 


examination  of  college  faculties  as  the  text-book  of; 
chemical  instruction. — St.  Louis  Medical  arid  Sur- 
gical Journal,  January,  1888. 

It  is  a  healthful  sign  when  we  see  a  demand  for 
a  third  edition  of  such  a  book  as  this.  This  edi- 
tion is  larger  than  the  last  by  about  seventy-five- 
pages,  and  much  of  it  has  been  rewritten,  thus- 
bringing  it  fully  abreast  of  the  latest  investiga- 
tions.— N.  T.  Medical  Journal,  Dec.  31, 1887. 


C SABLES,  T,  CBANSTOVN,  M.  2>.,  F,  C.  S,,  M,  S., 

Formerly  Asit.  Prof,  and  Demonst.  of  Chemistry  and  Chemical  Physics,  Queen's  College,  Belfast^ 

The  Elements  of  Physiological  and  Pathological  Chemistry.     A 

Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  463  pages,  with  38  woodcuts  and  1  colored  plate.     Cloth,  $3.50, 


Dr.  Charles  is  fully  impressed  with  the  import- 
ance and  practical  reach  of  his  subject,  and  he 
has  treated  it  in  a  competent  and  instructive  man- 
ner. We  cannot  recommend  a  better  book  than 
the  present.  la  fact,  it  fills  a  gap  in  medical  text- 
books, and  that  is  a  thing  which  can  rarely  be  said 


nowadays.  Dr.  Charles  has  devoted  much  space 
to  the  elucidation  of  urinary  mysteries.  He  does 
this  with  much  detail,  and  yet  in  a  practical  and 
intelligible  manner.  In  fact,  the  author  has  filled 
his  book  with  many  practical  hints. — Medical  Rec- 
ord, December  20,  1884. 


HOFFMAJnS^,  F,f  A,M»,  Fh,I>,,  &  FOWFM  F,JB,,  Fh,D., 

Public  Analyst  to  the  State  of  New  York.  Prof,  of  Anal.  Chem.  in  the  Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacists,  Pliysicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  verT 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.    Cloth,  $4.25. 


We  congratulate  the  author  on  the  appearance 
of  the  third  edition  of  this  work,  jiublished  for  the 
first  time  in  this  country  also.  It  is  admirable  and 
the  information  it  undertakes  to  supply  is  both 
extensive  and  trustworthy.  The  selection  of  pro- 
cesses for  determining  the  purity  of  the  substan- 
ces of  which  it  treats  is  excellent  and  the  descrip- 


tion of  them  singularly  explicit.  Moreover,  It  is 
exceptionally  free  from  typographical  errors.  We 
have  no  hesitation  in  recommending  it  to  those 
who  are  engaged  either  in  the  manufacture  or  the 
testing  of  medicinal  chemicals. — London  Pfiarma- 
ceutical  Jou/mal  and  Transactions^  1883. 


CLOWES,  FJRAJSTK,  D,  Sc,  London, 

Senior  Science- Master  at  the  High  School,  Newcastle-under-Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  very  handsome  royal  12mo.  volume  of  387  pages,  with  55  illustrations.  Cloth, 
$2.50. 


This  work  has  long  been  a  favorite  with  labora- 
tory instructors  on  account  of  its  systematic  plan, 
carrying  the  studentst«p  by  step  from  the  simplest 
Questions  of  chemical  analysis,  to  the  more  recon- 
dite problems.  Features  quite  as  commendable 
are  the  regularity  and  system  demanded  of  the 


student  in  the  performance  of  each  analysis. 
These  characteristics  are  preserved  in  the  present 
edition,  which  we  can  heartily  recommend  as  a  sat- 
isfactory guide  for  the  student  of  inorganic  chem- 
ical analysis. — Nero  York  Medical  Journal,  Oct.  9, 
1886. 


RALFE,  CJaCARLES  S.,  M.  D.,  F,  R.  C.  F,, 

Assistant  Physician  at  the  London  Hospital. 

Clinical  Chemistry.     In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 

See  Students^  Sei^  of  Manuals,  page  4. 
cine.  Dr.  Ralfe  is  thoroughly  acquainted  with  the 
latest  contributions  to  his  science,  and  it  is  quite 
refreshing  to  find  the  subject  dealt  with  so  clearly 
and  simply,  yet  in  such  evident  hai'mony  with  the 
modern  scientific  methods  and  spirit.— il/edicrB 
Record,  February  2, 1884. 


illustrations.  Limp  cloth,  red  edges,  $1.50. 
This  is  one  of  the  most  instructive  little  works 
that  we  have  met  with  in  a  long  time.  The  author 
is  a  physician  and  physiologist,  as  well  as  a  chem- 
ist, consequently  the  book  is  unqualifiedly  prac- 
tical, telling  the  physician  just  what  he  ougnt  to 
know,  of  the  applications  of  chemistry  in  medi- 


CLASSEN,  ALEXANDER, 

Professor  in  the  Royal  Polytechnic  School,  Aix-la-Chapelle. 

Elementary  Quantitative  Analysis.  Translated,  with  notes  and  additions,  by 
Edgae  F.  Smith,  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.     In  one  12mo.  volume  of  324  pages,  with  36  illus.     Cloth,  $2.00. 

It  is  probably  the  best  manual  of  an  elementary  and  then  advancing  to  the  analysis  of  ininerals  and 
nature  extant,  insomuch  as  its  methods  are  the  such  products  as  are  met  with  in  applied  chemis- 
best.  It  teaches  by  examples,  commencing  with  try.  It  is  an  indispensable  book  for  students  irb 
single   determinations,    followed  by  separations,    chemistry. — Boston  Journal  of  Chemistry,  Oct.  1878i. 


Lea  Brothers  &  Co.'s  Publications— Pharm.,  Mat.  Med.,  Therap.  11 


BRVWTOK,  T.  LAVJDEIt,  M,I>,,  I),Sc.,  F.B.S.,  F,B  C I> 

LectuTer  on  Materia  Medica  arui  Therapeutics  at  St.  Bartholomew^,  Hospital,  London  ttr  *' 

T    1^  •.?   5?°^  °^  Pharmacology,  Therapeutics  and  Materia  Medica- 

Including  the  Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of  Drags' 
New  (3d)   edition.    Octavo,  1305  pages,  230  illustrations.    Cloth,  §5.50  ;  leather  S6  50 

No  words  of  praise  are  needed  for  this  work,  for    -—*"  v-— ->  j-J-^^V     !■--.»  vo.OU 

it  has  already  spoken  for  itself  in  former  editions. 
It  was  by  unanimous  consent  placed  among  the 


foremost  books  on  the  subject  ever  published  in 
any  language,  and  the  better  it  is  known  and  studied 
the  more  highly  it  is  appreciated.  The  present 
edition  contains  much  new  matter,  the  insertion 
of  which  has  been  necessitated  by  the  advances 
rnade  in  various  directions  in  the  art  of  therapeu- 
tics, and  it  now  stands  unrivalled  in  its  thoroughly 
scientific  presentation  of  the  modes  of  drug  action. 
-No  one  who  wishes  to  be  fully  up  to  the  times  in 
this  science  can  afford  to  neglect  the  study  of  Dr. 
Brunton's  work.  The  indexes  are  excellent,  and 
add  not  a  little  to  the  practical  value  of  the  book. 
— Medical  Record,  May  25,  1S89. 

Nothing  so  original  and  so  complete  on  the  action 
of  drugs  on  the  body  generally  and  on  its  various 


parts,  has  appeared  during  the  life  of  the  present 
generation.  This  is  strong  language,  but  it  is  the 
truth.  The  great  merit  of  this  work  is  that  tho 
author  has  been  able  so  well  to  coordinate  facta 
into  an  intelligible  and  rational  .system  of  pharma- 
cology, and  henceforth  no  treatise  on  therapeutics 
will  be  considered  complete  which  does  not  in 
some  measure  adopt  this  method.  The  busy 
physician  will  approach  this  book  to  learn  some- 
thing that  will  better  fit  him  for  his  work,  and  on 
every  page  he  will  find  something  that  will  reward 
him  for  the  time  spent  in  its  perusal.  We  com- 
mend this  book  as  one  which  every  physician 
should  own  and  study.  It  is  a  work  which  if  once 
owned  will  be  likely  to  be  read  and  consulted  till 
the  covers  fall  off  from  much  ns&.—Boston  Medical 
and  Surgical  Journal,  Dec.  20,  1888. 


MAISCM,  JOMNM,,  JPhar.  D., 

Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 

A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  New  f3d)  edition,  thoroughly  revised.  In  one  handsome  royal  12mo. 
volume^ of  523  pages,  with  257  illustrations.     Cloth,  $3. 

author  are  a  guarantee  that  his  manual  is  well 
adapted  for  its  purpose,  viz. :  a  text- and  reference- 
book  for  students,  pharmacists  and  physicians,  con- 
taining the  most  recent  and  reliable  information 
in  regard  to  drags.— Cincinnati  Med.  News,NQy,  1887. 


Prof.  Maisch  is  one  of  the  most  distinguished 
pharmacists  of  this  country.  He  and  Prof.  Stille 
are  the  authors  of  The  National  Dispensatory, 
which  is  not  excelled  by  any  work  of  its  kind  ever 
published.    The  learning  and  experience  of  the 


BAMTMOJLOW,  ROBEMTS,  A,  M,,  M,  !>.,  XX.  X)., 

Professor  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  Coll.  of  Philadelphia 

New  Remedies  of  Indigenous  Source:  Their  Physiological  Actions  and 
Therapeutical  Uses.     In  one  octavo  volume  of  about  300  pages.     Preparing. 

I*AMMISS,  En  WARD, 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmacy. 
A  Treatise  on  Pharmacy :   designed  as  a  Text-book  for  the  Student,  and  as  a 
Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and   Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegand,  Ph.  G.     In  one  handsome 
octavo  volume  of  1093  pages,  with  256  illustrations.     Cloth,  $5 ;  leather, 

There  is  nothing  to  equal  Parrish's  Pharmacy 
in  this  or  any  other  language. — London  Pharma- 
ceutical Journal. 

No  thorough-going  pharmacist  will  fail  to  possess 
himself  of  so  useful  a  guide  to  practice,  and  no 
physician  who  properly  estimates  the  value  of  an 
accurate  knowledge  of  the  remedial  agents  em- 
ployed by  him  in  daily  practice,  so  far  as  their 
miscibility,  compatibility  and  most  effective  meth- 
ods of  combination  are  concerned,  can  afford  to 
leave  this  work  out  of  the  list  of  their  works  of 


reference.  The  country  practitioner,  who  must 
always  be  in  a  measure  his  own  pharmacist,  will 
find  it  indispensable. — Louisville  Medical  News, 
March  29,  1884. 

All  that  relates  to  practical  pharmacy — apparatus, 
processes  and  dispensing — has  been  arranged  and 
described  with  clearness  in  its  various  aspects,  so 
as  to  afford  aid  and  advice  alike  to  the  stuaentand 
to  the  practical  pharmacist.  The  work  is  judi- 
ciously illustrated  with  good  woodcuts — American 
Journal  of  Pharmacy,  January,  1884. 


MEMMAJnsr,  Dr,  X., 

Professor  of  Physiology  in  the  University  of  Zurich. 
Experimental  Pharmacology.    A  Handbook  of  Methods  for  Determining  the 
Physiological  Actions  of  Drugs.     Translated,  with   the  Author's  permission,  and   with 
extensive  additions,  by  Egbert  Meade  Smith,  M.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania.     12mo.,  199   pages,  with  32  illustrations.    Cloth,  $1.60. 

BBUCE,  J,  MITCHELL,  M.  X).,  F.  B,  C,  B., 

Physician  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Charing  Cross  Hospital,  L<yndon, 
Materia  Medica  and  Therapeutics.     An  Introduction  to  Eational  Treatment, 
i'ourth  edition.     12mo.,  591  pages.     Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  4. 

STILLE,  ALFBED,  M.  D.,  XX.  !>., 

Professor  of  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  m  the  Univ.  of  Penna.  '• 
Therapeutics  and  M.ateria  Medica.     A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal  Agents,  iacluding  their  Description  and  History.     Fourth  edition, 
revised  and  enlarged.    In  two  large  and  handsome  octavo  volumes,  containing  1936  pages. 
■Cloth,  $10.00 ;  leather,  $12.00._ 

GBIFFITH,  BOBEBT  EGLESFIELB,  M.  B, 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  and  Adminis- 
tering Officinal  and  other  Medicines.  The  wnole  adapted  to  Physicians  and  Pharmaceut- 
ists. Third  edition,  thoroughly  revised,  with  numerous  additions,  by  John  M  JVIaisch, 
Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  CoUege  of  Pharmacy. 
In  one  citavo  volume  of  775  pages,  with  38  illustrations.     Cloth,  $4.o0 ;  leather,  $5.50. 


12        Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therap. 


STILLE,  A,,  M,JJ,,LL,n,,  &  MAISCS,  J,  M.,Phar,I>,, 

Professor  Sm&ritus  of  the  Theory  and  Prac-  Prof,  of  Mat.  Med.  and  Botany  in  Phila, 

tice  of  Medicine  and  of  Clinical  Medicine  College  of  Pharmacy,  Sec'y  to  the  Ameri- 

in  the  University  of  Pennsylvania.  can  Pharmaceutical  Association. 

The  National  Dispensatory. 

CONTAINING  THE  NATURAL  HISTORY,  CHEMISTRY,  PHARMACY,  ACTIONS  AND   USES  OF 

MEDICINES,  INCLUDING  THOSE  RECOGNIZED  IN  THE  PHARMACOPCEIAS  OF  THE 

UNITED  STATES,  GREAT  BRITAIN  AND  GERMANY,  WITH  NUMEROUS 

REFERENCES  TO  THE  FRENCH  CODEX. 

Fourtli  edition  revised,  and  covering  the  new  British  Pharmacopoeia.  In  one  mag- 
nificent imperial  octavo  volume  of  1794  pages,  with  311  elaborate  engravings.  Price 
in  cloth,  $7.25  ;  leather,  raised  bands,  $8.00.  *^*2%is  work  will  he  furnished  with  Patent 
Ready  Reference  Thumb-letter  Index  for  $1.00  in  addition  to  the  price  in  any  style  of  binding. 

In  this  new  edition  of  The  National  Dispensatory,  all  important  changes  in  the 
recent  British  Pharmacopoeia  have  been  incorporated  throughout  the  volume,  while  in 
the  Addenda  will  be  found,  grouped  in  a  convenient  section  of  24  pages,  all  therapeutical 
novelties  which  have  been  established  in  professional  favor  since  the  publication  of  the 
third  edition  two  years  ago.  Since  its  first  publication.  The  National  Dispensatory 
has  been  the  most  accurate  work  of  its  kind,  and  in  this  edition,  as  always  before,  it  may 
be  said  to  be  the  representative  of  the  most  recent  state  of  American,  English,  German 
and  French  Pharmacology,  Therapeutics  and  Materia  Medica. 


It  is  with  much  pleasure  that  the  fourth  edition 
of  this  magnificeBt  work  is  received.  The  authors 
and  publishers  have  reason  to  feel  proud  of  this, 
the  most  comprehensive,  elaborate  and  accurate 
work  of  the  kind  ever  printed  in  this  country.  It 
is  no  wonder  that  it  has  become  the  standard  au- 
thority for  both  the  medical  and  pharmaceutical 
profession,  and  that  four  editions  have  been  re- 
quired to  supply  the  constant  and  increasing 
demand  since  its  first  appearance  in  1879.  The 
entire  field  has  been  gone  over  and  the  various 
articles  revised  in  accordance  with  the  latest 
developments  regarding  the  attributes  and  thera- 
peutical action  of  drugs.    The  remedies  of  recent 


discovery  have  received  due  attention. — Kansas 
City  Medical  Index,  Nov.  1887. 

We  think  it  a  matter  for  congratulation  that  the 
profession  of  medicine  and  that  of  pharmacy  have 
shown  such  appreciation  of  this  great  work  as  to  call 
for  four  editions  within  the  comparatively  briel 
period  of  eight  years.  The  matters  with  which  it 
deals  are  of  so  practical  a  nature  that  neither  the 
physician  nor  the  pharmacist  can  do  without  the 
latest  text-books  on  them,  especially  those  that  are 
so  accurate  and  comprehensive  as  this  one.  The 
book  is  in  every  way  creditable  both  to  the  authors 
and  to  the  publishers. — New  York  Medical  Journal, 
May  21, 1887. 


FAMQUSABSOW,  MOBBBT,  M.  J>.,  F,  B,  C,  JP.,  LL.  J>., 

Lecturer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School,  London. 

A  Guide  to  Therapeutics  and  Materia  Medica.  New  (fourth)  American, 
from  the  fourth  English  edition.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia,  iiy 
Frank  Woodbury,  M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  and  Clinical 
Medicine  in  the  Medico-Chirurgical  College  of  Philadelphia.  In  one  handsome  12mo. 
volume  of  581  pages.     Cloth,  $2.60.    Just  ready. 


It  may  correctly  be  regarded  as  the  most  modem 
work  of  its  kind.  It  is  concise,  yet  complete. 
Containing  an  account  of  all  remedies  that  have 
a  place  in  the  British  and  United  States  Pharma- 
copoeias, as  well  as  considering  all  non-official  but 
important  new  drugs,  it  becom  es  in  fact  r  miniature 
dispensatory. — Pacific  Medical  Journal,  June,  1889. 

Farquharson's  Guide  is  becoming  more  widely 
known,  and  doubtless  will  be  more  acceptable  with 
each  revision,  as  it  has  in  this.    It  is  just  the  book 


the  young  doctor  will  consult  with  profit  in  very 
many  of  nis  daily  emergencies,  and  to  all  such, 
yes,  and  to  many  of  the  grave  and  reverend 
seniors  we  commend  it  most  heartily. — North 
Carolina  Medical  Journal,  July,  1889. 

We  have  in  the  preceding  issues  of  this  journal 
had  occasion  to  call  attention  to  the  previous  edi- 
tions of  this  excellent  work,  which  m  its  present 
form  retains  all  the  special  features  of  its  former 
editions.— -SowiAern  Practitioner,  July,  1889. 


BDBS,  BOBEBT  T.,  M,  J),, 

Jackson  Professor  of  Clinical  Medicine  in  Harvard  University,  Medical  Department. 

A  Text-Book  of  Therapeutics  and  Materia  Medica.    Intended  for  the 
Use  of  Students  and  Practitioners.    Octavo,  544  pages.    Cloth,  $3.50 ;  leather,  $4.50. 

cine.  Such  they  can  find  in  the  present  author. 
All  the  newest  drugs  of  promise  are  treated  of. 
The  clinical  index  at  the  end  will  be  found  ver^ 
useful.    We  heartily  commend  the  book  and  con 


The  treatise  will  be  found  to  be  concise  and 
practical,  bringing  the  subject  down  to  the  latest 
developments  of  therapeutics  and  pharmacology. 
The  student  and  practitioner  will  find  the  book  a 
valuable  one  for  reference  and  study,  the  former 
being  facilitated  by  a  full  and  excellent  index.— 
St.  Louis  Medical  and  Surgical  Journal,  Jan.  1888. 

The  present  work  seem  s  destined  to  take  a  prom- 
inent place  as  a  text-book  on  the  subjects  of  which 

treats.  It  possesses  all  the  essentials  which  we 
expect  in  a  book  of  its  kind,  such  as  conciseness, 
clearness,  a  judicious  classification,  and  a  reason- 
able degree  of  dogmatism.  The  style  deserves 
the  highest  commendation  for  its  dignity  and 
purity  of  diction.  The  student  and  young  practi- 
tioner need  a  safe  guide  in  this  branch  of  medi- 


gratulate  the  author  on  having  produced  so  good 
a  one.— iV.  Y.  Medical  Journal,  Feb.  18, 1888. 

Dr.  Edes'  book  represents  better  than  any  older 
book  the  practical  therapeutics  of  the  present 
day.  The  book  is  a  thoroughly  practical  one.  The 
classification  of  remedies  has  reference  to  their 
therapeutic  action,  and  such  a  classification  will 
always  meet  the  approval  of  the  student.  The  rela- 
tive importance  of  different  remedies  is  indicated 
by  the  space  devoted  to  each,  and  by  the  use  of 
larger  type  in  the  titles  of  the  more  important 
articlea.— Pharmaceutical  Era,  Jan.  1888. 


Lea  Brothers  &  Co.'s  Publications— Patliol.,  Histol. 


13 


JPATNE,  JOSEFS  F,,  M.  D.,  F.  B,  C.  P., 

Member  of  the  Pathological  Society,  Senior  Assistant  Physician  and  Lecturer  on  Patholoaical  Anat- 
omy, St.  Thomas'  Hospital,  London. 

_      A  Manual  of  General  Pathology.     Designed  as  an  Introduction  to  the  Prac- 
tice of  Medicine.    Octavo  of  524  pages,  with  152  illus.  and  a  colored  plate.    Cloth,  $3.50 


Knowing,  as  a  teacher  an!f  examiner,  the  exact 
needs  of  medical  students,  the  author  has  in  the 
work  before  us  prepared  for  their  especial  use 
what  we  do  not  hesitate  to  say  is  the  best  introduc- 
tion to  general  pathology  that  we  have  yet  ex- 
amined. A  departure  which  our  author  has 
taken  is  the  greater  attention  paid  to  the  causa- 
tion of  disease,  and  more  especially  to  the  etiologi- 


cal factors  in  those  diseases  now  with  reasonable 
certainty  ascribed  to  pathogenetic  microbes.  In 
this  department  he  has  been  very  full  and  explicit, 
not  only  in  a  descriptive  manner,  but  in  the  tech- 
nique of  investigation.  The  Appendix,  giving 
methods  of  reseaich,  ia  alone  worth  the  price  of  the 
book,  several  times  over,  to  every  student  of 
pathology. — St.  Louis  Med.  and  Surg,  /owr.,  Jan,'89. 


SFWJ!^,  NICHOLAS,  M.D.,  Fh,D., 

Professor  of  Principles  of  Surgery  and  Surgical  Pathology  in  Rush  Medical  College,  Chicago. 
Surgical  Bacteriology.     In  one  handsome  octavo  of  259  pages,  with  13  plates, 
of  which  9  are  colored.     Cloth,  $1.75.     Just  ready. 

The  author  in  this  excellent  monograph  has  very 
concisely  yet  fully  and  comprehensively  gone  over 
the  iield,  and  placed  before  the  medical  public  a 
most  valuable  treatise  on  the  subject.  "We  know 
of  no  one  better  qualified  for  the  task  he  has 
assumed,  and  doubt  if  anyone  could  have  dis- 
charged the  duty  so  well.  Those  who  would  not 
be  behind  the  wonderful  developments  of  the  day 


will  make  a  mistake  in  not  supplying  themselves 
with  this  work.  The  facts  in  regard  to  this  im- 
portant subject  are  made  so  plain  and  considered 
in  such  a  satisfactory  manner  that  we  can  but 
regard  it  as  one  of  the  most  important  contributions 
to  the  medical  literature  of  the  year. — Southern 
Practitioner,  June  1, 1889. 


COATS,  JOSEFM,  M,  J).,  F.  F.  F.  S., 

Pathologist  to  the  Glasgow  Western  Infirmary. 

A  Treatise  on  Pathology.    In  one  very  handsome  octavo  volume  of  829  pages, 
with  339  beautiful  illustrations.    Cloth,  $5.50 ;  leather,  $6.50. 


The  work  before  us  treats  the  subject  of  Path- 
ologjr  more  extensively  than  it  is  usually  treated 
In  similar  works.  Medical  students  as  well  as 
physicians,  who  desire  a  work  for  study  or  refer- 
ence, that  treats  the  subjects  in  the  various  de- 
partments in  a  very  thorough  manner,  but  without 
prolixity,  will  certainly  give  this  one  the  prefer- 
ence to  any  with  which  we  are  acquainted.  It  sets 


forth  the  most  recent  discoveries,  exhibits,  in  an 
interesting  manner,  the  changes  from  a  normal 
condition  effected  in  structures  by  disease,  and 
points  out  the  characteristics  of  various  morbid 
agencies,  so  that  they  can  be  easily  recognized.  But, 
not  limited  to  morbid  anatomy,it  explains  fully  how 
the  functions  of  organs  are  disturbed  by  abnormal 
conditions.— Oincinnaft  Medical  News,  Oct.  1883. 


GJRFBW,  T.  MENMY,  M,  JD,, 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hospital  Medical  School,  London. 
Pathology  and  Morbid  Anatomy.     New  (sixth)  American  from  the  seventh 
revised  English  edition.    In  one  octavo  vol.  of  539  pp.,  with  167  engravings.  Cloth,  $2.75. 
Just  ready. 

WOODHFAD,  G.  SIMS,  M,  D.,  F.  M.  C.  F.  E., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 
Practical  Pathology.    A  Manual  for  Students  and  Practitioners.    In  one  beau- 
tiful octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.     Cloth,  $6.00. 

It  forms  a  real  guide  for  the  student  and  practi-  themselves  with  this  manual.  The  numerous 
tioner  who  is  thoroughly  In  earnest  in  his  en-  drawings  are  not  fancied  pictures,  or  merely 
deavor  to  see  for  himself  and  do  for  himself.  To  schematic  diagrams,  but  they  represent  faithfully 
the  laboratory  student  it  will  be  a  helpful  com-  the  actual  images  seen  under  the  microscope. 
panion,  and  all  those  who  may  wish  to  familiarize  The  author  merits  all  praise  for  having  produced 
themselves  with  modern  methods  of  examining  a  valuable  work. — Memcal  Record,  May  31, 1884. 
morbid  tissues   are   strongly  urged   to   provide 


SCHAFEB,  EnWABn  A,,  F.  M.  S., 

Assistant  Professor  of  Physiology  in  University  College,  London. 

The  Essentials  of  Histology.     In  one  octavo  volume  of  246  pages,  with 

281  illustrations.    Cloth,  $2.25. 


This  admirable  work  was  greatly  needed.  It 
has  been  written  with  the  object  of  supplying 
the  student  with  directions  for  the  microscopical 
examination  of  the  tissues,  which  are  given  in  a 
clear  and  understandable  way.  Although  espe- 
cially adapted  for  laboratory  work,  at  the  same 


time  it  is  Intended  to  serve  as  an  elementary 
text-book  of  histology,  comprising  all  the  essen- 
tial facts  of  the  science.  The  author  has  recom- 
mended only  those  methods  upon  which  long  ex- 
perience has  proved  that  full  dependence  can  be 
placed. — The  Physician  and  Surgeon,  July,  1887. 


KLEIN,  E.,  M.  !>.,  F,  B.  S., 

Joint  Lecturer  on  General  Anat.  and  Phys.  in  the  Med.  School  of  St.  Bartholomew's  Hasp.,  London. 

Elements  of  Histology.     Fourth  edition.    In  one  12mo.  volume  of  376  pages, 

with  194  illus.    Limp  cloth,  $1.75.     Just  ready.    See  Students'  Series  of  Manuxils,  page  4. 


Considered  with  regard  to  its  contents,  it  can 
only  be  looked  on  as  a  large  and  comprehensive 
volume.  New  and  original  illustrations  have  been 
added,  with  the  help  of  which  the  structure  of  each 
tissue  becomes  clear  to  the  reader.    A  copious 


index  affords  a  ready  reference  to  the  histology  of 
every  tissue  and  organ,  and  presents,  at  the  same 
time,  a  complete  glossary  of  the  scientific  terms. — 
Provincial  Medical  Journal,  May  1, 1889. 


FEFFEB,  A,  J,,  M.  B.,  M,  S,,  F,  B.  C.  S., 

Surgeon  and  Lecturer  at  St.  Mary's  Hospital,  London. 
Surgical  Pathology.    In  one  pocket-size  12mo.  volume  of  511  pages,  with  81 
illustrations.  Limp  cloth,  red  edges,  $2.00.    See  Students'  Series  of  Manuals,  page  4. 

Its  form  is  practical,  its  language  is  clear,  and  in  it  nothing  that  is  unnecessary.  The  list  of 
the  information  set  forth  is  well-arranged,  well-  subjects  covers  the  whole  range  of  surgery.— iVew 
indexed  and  well- illustrated.  The  student  will  find     York  Medical  Journal,  May  31, 1884. 


14 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 


FLINT,  AUSTIN,  M.  D.,  LI.  D. 

Prof,  of  the  Principles  and  Practice  of  Med.  and  of  Clin.  Med.  in  Bellevue  Hospital  Medical  College,  N.  7, 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 
the  use  of  Students  and  Practitioners  of  Medicine.  New  (sixt^)  edition,  thoroughly  re- 
vised and  rewritten  by  the  Author,  assisted  by  "WrLLiAii  H.  Welch,  M.  D.,  Professor  of 
Pathology,  Johns  Hopkins  University,  Baltimore,  and  Austin  Flixt,  Jr.,  M.  D.,  LL.  D., 
Professor  of  Physiology,  Bellevue  Hospital  Medical  College,  IST.  Y.  In  one  very  handsome 
octavo  volume  of  1160  pages,  with  illustratious.    Cloth,  $5.50  ;   leather,  ?6.50. 

A  new  edition  of  a  work  of  such  established  rep-  '  general  approval  by  medical  students  and  practi- 
ntationas  Flint's  Medicine  needs  but  few  words  to  tioners  as  the  work  of  Professor  Flint.  In  all  the 
commend  it  to  notice.  It  may  in  truth  be  said  to  :  medical  colleges  of  the  United  States  it  is  the  fa- 
embody  the  fruit  of  his  labors  in  clinical  medicine,  ,  vorite  work  upon  Practice;  and,  as  we  have  stated 
ripened  by  the  experience  ofa  long  life  devoted  to  i  before  in  alluding  to  it,  there  is  no  other  medical 
its  pursuit.  America  may  well  be  proud  of  having  work  that  can  be  so  generally  found  in  the  libra- 
produced  a  man  whose  indefatigable  industry  and  |  ries  of  physicians.  In  every  state  and  territory 
gifts  of  genius  have  done  so  much  to  advance  med-  i  of  this  vast  country  the  book  that  will  be  most  likely ' 
icine;  and  all  English-reading  students  must  be    to  be  found  in  the  office  of  a  medical  man,  whether 

frateful  for  the  work  which  he  nas  left  behind  bim.  !  in  city,  town,  village,  or  at  some  cross-roads,  is 
t  has  few  equals,  either  in  point  of  literary  excel- I  Flint's  Practice.  We  make  this  statement  to  a 
lence,  or  of  scientific  learning,  and  no  one  can  i  considerable  extent  from  personal  observation,  and 
study  its  pages  without  being  struck  by  the  lu-  I  it  Is  the  testimony  also  of  others.  An  examina- 
cidity  and  accuracy  which  characterize  them.  It  |  tion  shows  that  very  considerable  changes  have 
is  qualities  such  as  these  which  render  it  so  valu-  been  made  in  the  sixth  edition.  The  work  may  un- 
able for  its  purpose,  and  give  it  a  foremost  place  doubtedly  be  regarded  as  fairly  representing  the 
among  the  text-books  of  this  generation. — The  present  state  of  the  science  of  medicine,  and  as 
London  Lancet,  March  12, 1887.  i  reflecting  the  views  of  those  who  exemplify  in 

No  text-book  on  the  principles  and  practice  of  i  their  practice  the  present  stage  of  progress  of  med- 
medicine  has  ever  met  in  this  country  with  such  ;  ical  a-rt.— Cincinnati  Medical  News,  Oct.  1886. 


SARTSSOBNE,  HBNRY,  M.  D.,  LL.  D., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Students  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.     Cloth,  $2.75 ;  haK  bound,  $3.00. 

Within  the  compass  of  600  pages  it  treats  of  the 
history  of  medicine,  general  pathology,  general 
symptomatology,  and  physical  diagnosis  (including 
laryngoscope,  ophthalmoscope,  etc.),  general  ther- 
apeutics, nosology,  and  special  pathology  and  prac- 
tice. There  is  a  wonderful  amount  of  information 
contained  in  this  work,  and  '.i  is  one  of  the  best 
of  its  kind  that  we  have  seen. — Glasgow  Medical 
Journal,  Nov.  1882. 

An  indispensable  book.  No  work  ever  exhibited 
&  better  average  of  actual  practical  treatment  than 


this  one;  and  probably  not  one  writer  in  our  day 
had  a  better  opportunity  than  Dr.  Hartshorne  for 
condensing  all  the  views  of  eminent  practitioners 
into  a  12mo.  The  numerous  illustrations  will  be 
very  useful  to  students  especially.  These  essen- 
tials, as  the  name  suggests,  are  not  intended  to 
supersede  the  text-books  of  Flint  and  Bartholow, 
but  they  are  the  most  valuable  in  affording  the 
means  to  see  at  a  glance  the  whole  literature  of  any 
disease,  and  the  most  valuable  treatment. — Chicago 
Medical  Journal  and  Examiner,  April,  1882. 


BHISTOWJE,  JOSN  STUM,  M.  D.,  F.  R.  C.  F., 

Physician  and  Joint  Lecturer  on  Medicine  at  St.  Thomas''  Hospital,  London. 
A  Treatise  on  the  Practice  of  Medicine.     Second  American  edition,  revised 
by  the  Author.    Edited,  with  additions,  by  James  H.  Hutchinson,  M.D.,  physician  to  the 
Pennsylvania  Hospital.     In  one  handsome  octavo  volume  of  1085  pages,  with  illustrations. 
Cloth,  $5.00 ;  leather,  $61)0. 

The  book  is  a  model  of  conciseness,  and  com- 
bines, as  successfully  as  one  could  conceive  it  to 
be  possible,  an  encyclopaedic  character  with  the 
smallest  dimensions.  It  differs  from  other  admi- 
rable text-books  in  the  completeness  with  which 
it  covers  the  whole  field  of  medicine. — Michigan 
Medical  Neics,  May  10, 1880. 

His  accuracy  in  the  portraiture  of  disease,  his 
care  in  stating  subtle  points  of  diagnosis,  and  the 
faithfully  given  pathology  of  abnormal  processes 
have  seldom  been  surpassed.  He  embraces  many 
diseases  not  usually  considered  to  belong  to  theory 


and  practice,  as  skin  diseases,  syphilis  and  insan- 
ity, but  they  will  not  be  objected  to  by  readers,  as 
he  has  studied  them  conscientiously,  and  drawn 
from  the  life. — Medical  and  Surgical  Reporter,  De- 
cember 20,  1879. 

The  reader  will  find  every  conceivable  subject 
connected  with  the  practice  of  medicine  ably  pre- 
sented, in  a  style  at  once  clear,  int-eresting  and 
concise.  The  additions  made  by  Dr.  Hutchinson 
are  appropriate  and  practical,  and  greatly  add  to 
its  usefulness  to  American  readers. — Buffalo  Med- 
ical and  Surgical  Journal,  March,  1880. 


WATSON,  SIM  TJSOMAS,  M.  D., 

Late  Physician  in  Ordinary  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  A  new  American 
from  the  fifth  English  edition.  Edited,  with  additions,  and  190  illustrations,  by  Henry 
Hartshorne,  A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
In  two  large  octavo  volumes  of  1840  pages.     Cloth,  $9.00  ;  leather,  $11.00. 


LECTURES  ON  THE  STUDY  OF  FEVER.  By 
A.  Hudson,  M.  D.,  M.  R.  I.  A.  In  one  octavo 
volume  of  308  pages.    Cloth,  «2.50. 

A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  C.  C.    InoneSvo.  vol.  of354pp.    Cloth,  $2.26. 


LA  ROCHE  ON  YELLOW  FEVER,  considered  in 
its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  large  and  hand- 
some octavo  volumes  of  1468  pp.    Oloth,  $7.00. 


Lea  Brothers  &  Co.'s  Publications — System  of  Med. 


16 


For  Sale  by  Subscription  Only. 


A 


System  of  Practical  Medicine. 

B  Y  AMERICAN  A  UTHOBS. 

Edited  by  WILLIAM   PEPPER,  M.  D.,  LL.  D., 

PROVOST  AND  PROFESSOR  OP  THE  THEORY   AND   PRACTICE  OF  MEDICINE  AND  OF 
OIiINICAIi  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA, 

Assisted  by  Louis  Starr,  M.  D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania. 

The  complete  work,  in  five  volumes,  containing  6573  pages,  vnth  198  illustrations,  is  now  ready. 
Price  per  volume,  cloth,  $5;  leather,  $6  ;  half  Russia,  raised  hands  and  open  hack,  $7. 


In  this  great  work  American  medicine  is  for  the  first  time  reflected  by  its  worthiest 
teachers,  and  presented  in  the  full  development  of  the  practical  utility  which  is  its  pre- 
eminent characteristic.  The  most  able  men — from  the  East  and  the  West,  from  the 
North  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  opportunities  for  study  and  practice — have  united  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience. 

The  distinguished  editor  has  so  apportioned  the  work  that  to  each  author  has  been 
assigned  the  subject  which  he  is  peculiarly  fitted  to  discuss,  and  in  which  his  views 
will  be  accepted  as  the  latest  expression  of  scientific  and  practical  knowledge.  The 
practitioner  will  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aspect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  treatment  of  special  disease.  So  wide  is  the  scope  of  the 
work  that,  with  the  exception  of  midwifery  and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinary 
organs,  of  the  skin,  of  the  nerves,  hygiene  and  sanitary  science,  and  medical  ophthalmology 
and  otology.  Moreover,  authors  have  inserted  the  formulas  which  they  have  fou  ad  most 
efficient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regai  ded  as  a 
Complete  Library  of  Practical,  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount  of  practical  information  fur- 
nished, it  has  been  impossible  to  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5600  beautifully  printed  pages,  and  embodying  the  matter  of  about  15  ordinary 
octavos.     Illustrations  are  introduced  wherever  requisite  to  elucidate  the  text. 

A   detailed  prospectus  will  he  sent  to  any  address  on  application  to  the  publishers. 


These  two  volumes  bring  this  admirable  work 
to  a  close,  and  fully  sustain  the  high  standard 
reached  by  the  earlier  volumes;  we  have  only 
therefore  to  echo  the  eulogium  pronounced  upon 
them.  We  would  warmly  congratulate  the  editor 
and  his  collaborators  at  the  conclusion  of  their 
laborious  task  on  the  admirable  manner  in  which, 
from  first  to  last,  they  have  performed  their  several 
duties.  They  have  succeeded  in  producing  a 
work  which  will  long  remain  a  standard  work  of 
reference,  to  which  practitioners  will    look    for 

fuidance,  and  authors  will  resort  for  facts, 
'rom  a  literary  point  of  view,  the  work  is  without 
any  serious  blomlsh,  and  in  respect  of  production, 
it  has  the  beautiful  finish  that  Americans  always 
give  their  works. — Edinburgh  MedicdL  Journal,  Jan. 
1887. 

*  *  The  greatest  distinctively  American  work  on 
the  practice  of  medicine,  and,  indeed,  the  super- 
lative adjectiv«  would  not  be  inappropriate  were 
even  all  other  productions  placed  in  comparison. 
An  examination  of  the  fire  volumes  is  sufficient 
to  convince  one  of  the  magnitude  of  the  ent«r- 
prise,  and  of  the  success  which  has  attended  its 
fulfilment.— TAe  Medical  Age,  July  26,  1886. 

This  huge  volume  forms  a  fitting  close  to  the 
great  system  of  medicine  which  in  so  short  a  time 
has  won  so  high  a  place  in  medical  literature,  and 
has  done  such  credit  to  the  profession  in  this 
country.  Among  the  twenty-three  contributors 
are  the  names  of  the  leading  neurologists  in 
America,  and  most  of  the  work  in  the  volume  is  of 
the  highest  ordex.— Boston  Medical  aitd  Surgical 
Journal,  July  21, 1887. 

We  consider  it  one  of  the  grandest  works  on 
Practical  Medicine  in  the  English  language.  It  is 
a  work  of  which  the  profession  of  this  country  can 
feel   proud.     Written   exclusively  by  American 


physicians  who  are  acquainted  with  all  the  varie- 
ties of  climate  in  the  United  States,  the  character 
of  the  soil,  the  manners  and  customs  of  the  peo- 
ple, etc.,  it  is  peculiarly  adapted  to  the  wante 
of  American  practitioners  of  medicine,  and  it 
seems  to  us  that  every  one  of  them  would  desire 
to  have  it.  It  has  been  truly  called  a  "Complete 
Library  of  Practical  Medicine,"  and  the  general 
practitioner  will  require  little  else  in  his, round 
of  professional  duties. — Cincinnati  Medical  JVeics, 
March,  1886. 

Each  of  the  volumes  is  provided  with  a  most 
copious  index,  and  the  work  altogether  promises 
to  be  one  which  will  add  much  to  the  medical 
literature  of  the  present  century,  and  reflect  great 
credit  upon  the  scholarship  and  practical  acumen 
of  its  authors. —  TTie  London  Lancet,  Oct.  3,  1885. 

The  feeling  of  proud  satisfaction  with  which  the 
American  profession  sees  this,  its  representative 
system-of  practical  medicine  issued  to  the  medi- 
cal world,  IS  fully  justified  by  the  character  of  the 
work.  The  entire  caste  of  the  system  is  in  keep- 
ing with  the  best  thoughts  of  the  leaders  and  fol- 
lowers of  our  home  school  of  medicine,  and  the 
combination  of  the  scientific  study  of  disease  and 
the  practical  application  of  exact  and  experimen- 
tal knowledge  to  the  treatment  of  human  mal- 
adies, makes  every  one  of  us  share  in  the  pride 
that  has  welcomed  Dr.  Pepper's  labors.  Sheared 
of  the  prolixity  that  wearies  the  readers  of  the 
German  school,  the  articles  glean  these  same 
fields  for  all  that  is  valuable.  It  is  the  outcome 
of  American  brains,  and  is  marked  throughout 
by  much  of  the  sturdy  independence  of  thought 
and  originality  that  is  a  national  characteristic. 
Yet  nowhere  is  there  lack  of  study  of  the  most 
advanced  views  of  the  d&y.— North  Carolina  Medi- 
cal Journal,  Sept.  1886. 


16  Lea  Brothers  &  Co.'s  Publications — Clinical  Med.,  etc. 

FOTSJERGILLf  J,  M,,  M,  J).,  Edin,,  M,  B,  C.  I*,,  Lond,, 

Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics.  New  (third)  edition.    In  one  8vo.  vol.  of  661  pages.    Cloth,  $3.75 ;  leather,  $4.75. 


To  have  a  description  of  the  normal  physiologi- 
cal processes  of  an  organ  and  of  the  methods  of 
treatment  of  its  morbid  conditions  brought 
together  in  a  single  chapter,  and  the  relations 
between  the  two  clearly  stated,  cannot  fail  to  prove 
a  great  convenience  to  many  thoughtful  but  busy 
physicians.  The  practical  value  of  the  volume  is 
greatly  increased  by  the  introduction  of  many 
prescriptions.  That  the  profession  appreciates 
that  the  author  has  undertaken  an  important  work 
and  has  accomplished  it  is  shown  by  the  demand 
for  this  third  edition.— JV.  T.  Med.  Jour.,  June  11,'87. 


This  is  a  wonderful  book.  If  there  be  such  a 
thing  as  "medicine  made  easy,"  this  is  the  work  to 
accomplish  this  result. —  Va.  Med.  Month.,  June,'87. 

It  is  an  excellent,  practical  work  on  therapeutics, 
well  arranged  and  clearly  expressed,  useful  to  the 
student  and  young  practitioner,  perhaps  even  to 
the  old. — Dublin  Journal  of  Medical  Science,  March, 
1888. 

We  do  not  know  a  more  readable,  practical  and 
useful  work  on  the  treatment  of  disease  than  the 
one  we  have  now  before  na.— Pacific  Medical  and 
Surgical  Journal,  October,  1887. 


VAVGHAN,  nCTOJR  C,  P/i.  D.,  M.  JD., 

Prof.  ofPhys.  and  Path.  Chem.  and  Assoc.  Prof,  of  Therap.  and  Mat.  Med.  in  the  Univ.  of  Mich. 

and  ]!fOrY,  FItJE DBBICK  G,,  M.  D. 

Instructor  in  Hygiene  and  Phys.  Chem.  in  the  Univ.  of  Mich. 

Ptomaines  and  Leueomaines,  or  Putrefactive   and   Physiological 
Alkaloids.     In  one  handsome  12mo.  volume  of  311  pages.     Just  ready.     Cloth,  $1.75. 


This  book  is  what  has  been  wanted  for  some 
years  by  the  medical  profession.  The  subject  of 
ptomaines  and  leueomaines,  so  far  as  their  disease- 
producing  relations  are  concerned,  has  been  under 
special  study  scarcely  more  than  a  decade,  but 
within  that  period  facts  have  been  discovered 
upon  which  theories  of  permanent  standing  have 
been  built,  until  now  the  practitioner  is  far  be- 
hind the  times  if  he  does  not  appreciate  the 
importance  of  ptomaines.  This  is  the  first  attempt 
made  to  collect   into  book  form  the  results  of 


observers  and  experimenters  on  micro-organisms, 
and  to  trace  the  relationship  of  cause  and  effect 
of  the  putrefacative  alkaloids.  We  congratulate 
the  autnors  upon  the  successful  presentation  of 
the  current  views  ou  the  subject  in  such  manner 
as  to  make  them  easily  comprehensible,  while  to 
the  practitioner,  after  he  has  carefully  read  the 
book,  it  will  serve,  also,  as  a  frequent  reference 
work,  because  of  the  technical  information  it  gives. 
Va.  Medical  Monthly,  Sept  1888. 


BBTWOLDS,  J,  BTISSBLL,  M,  X>., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 

A  System  of  Medicine.  With  notes  and  additions  by  Henr"?  Haetshorne, 
A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  3056  double-columned  pages,  with  317  illustra- 
tions. Price  per  volume,  cloth,  $5.00 ;  sheep,  $6.00 ;  very  handsome  half  Eussia,  raised  bands, 
$6.50.     Per  set,  cloth,  $15;  leather,  $18.    Sold  only  by  subscription. 

8TILLB9  ALFUBJDf  M,  2).,  ii.  !>., 

Professor  Emeritus  of  the  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  ttie  Univ.  of  Penna. 
Cholera:   Its  Origin,  History,  Causation,  Symptoms,  Lesions,  Prevention  and  Treat- 
ment. In  one  handsome  12mo.  volume  of  163  pages,  with  a  chart.  Cloth,  $1.25. 

FUnOATSOJV,  JAMBS,  M.  D.,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc 

Clinical  Manual  for  the  Study  of  Medical  Cases.  With  Chapters 
by  Prof.  Gairdner  on  the  Physiognomy  of  Disease ;  Prof.  Stephenson  on  Diseases  of 
the  Female  Organs;  Dr.  Eobertson  on  Insanity;  Dr.  GemmeU  on  Physical  Diagnosis; 
Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor  on  Case- 
taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  New  edition. 
In  one  12mo.  volume  of  682  pages,  with  158  illustrations.    Cloth,  $2.50. 


This  manual  is  one  of  the  most  complete  and 
perfect  of  its  kind.    It  goes  thoroughly  into  the 

?uestion  of  diagnosis  from  every  possible  point, 
t  must  lead  to  a  thoroughness  of  observation,  an 
examination  in  detail  of  every  scientific  appliance, 


and  a  study  of  means  to  the  end  which  cannot 
fail  in  laying  an  excellent  foundation  for  the 
student  for  future  success  as  an  able  diagnostician. 
—Medical  Record,  August  13, 1887. 


FENWICK,  SAMUEL,  M.  J)., 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  and 
enlarged  English  edition.  In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 
87  illustrations  on  wood.     Cloth,  $2.25. 

HABEBSSOJ^,  S.  O.,  M,  D., 

Senior  Physician  to  and  late  Lect.  on  Principles  and  Practice  of  Med.  at  Ony^s  Hospital,  London. 
On  the  Diseases  of  the  Abdomen ;    Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  CEsophagus,  Caecum,  Intestines  and  Peritoneum.  Second 
American  from  third  enlarged  and  revised  English  edition.    In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.    Cloth,  $3.50. 

TANNEB,  THOMAS  SAWKBS,  M,  1>. 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 
from  the  second  London  edition.  Eevised  and  enlarged  by  TrLBUBY  Fox,  M.  D. 
In  one  small  12mo.  volume  of  362  pages,  with  illustrations.    Cloth,  $1.50. 


Lea  Brothers  &  Co.'s  Publications — Hygiene,  Electr.,  Pract.       17 


BABTSOLOW,  BOBEBTS,  A,  M,,  M,  X>.,  ii.  J)., 

Brof.  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  Coll.  of  Phila.,  etc. 
Medical  Electricity.     A  Practical  Treatise  on  the  Applications  of  Electricity 
to  Medicine  and  Surgery.     New  (third)  edition.     In  one  very  handsome  octavo  volume  of 
308  pages,  with  110  illustrations.    Cloth,  $2.50. 


_  The  fact  that  this  work  has  reached  its  third  edi- 
tion in  six  years,  and  that  it  has  been  kept  fully 
abreast  with  the  increasing  use  and  knowledge  of 
electricity,demonstrates  its  claim  to  be  considered 
a  practical  treatise  of  tried  value  to  the  profession. 
The  matter  added  to  the  present  edition  embraces 
the  most  recent  advances  in  electrical  treatment. 
The  illustrations  are  abundant  and  clear,  and  the 
work  constitutes  a  full,  clear  and  concise  manual 
well  adapted  to  the  needs  of  both  student  and 
practitioner.— TTie  Medical  News.  IMay  14, 1887. 

This  "practical  treatise  on  tne  applications  of 
electricity  to  medicine  and  surgery"  has  grown  to 
be  so  important  a  work  that  every  practitioner 


should  read  it,  especially  when  it  is  recalled  what 
possibilities  lie  in  the  path  of  the  further  study  of 
the  therapeutics  of  electricity.  Dr.  Bartholow  has 
here  presented  the  profession  with  a  concise  work 
that,  beginning  with  elementary  descriptions  and 
I)rinciples,  gradually  grows,  page  by  page,  into  a 
niaguificently  practical  treatise,  descrioing  opera- 
tions in  detail,  and  giving  records  of  successes 
that  prove  electricity  to  be  marvellous  as  a  curative 
agent  in  many  forms  of  disease.  The  doctor  can- 
not now  do  better  than  to  possess  himself  of  Dr. 
Bartholow's  treatise,  just  as  it  is. —  Virginia  Medi- 
cal Monthly,  June,  1887. 


BICSABDSOW,  B,  W.,  M.D,,  LL.  JD.,  F,B.S,, 

Fellow  of  the  Royal  College  of  Physicians,  London. 

Preventive  Medicine.    In  one  octavo  volume  of  729  pages.    Cloth,  $4;  leather, 
$5 ;  very  handsome  half  Russia,  raised  bands,  $5.50. 


Dr.  Richardson  has  succeeded  in  producing  a 
work  which  is  elevated  in  conception,  comprehen- 
sive in  scope,  scientific  in  cliaracter,  systematic  in 
arrangement,  and  which  is  written  in  a  clear,  con- 
cise and  pleasant  manner.  He  evinces  the  happy 
faculty  of  extracting  the  pith  of  what  is  known  on 
the  subject,  and  of  presenting  it  in  a  most  simple, 
intelligent  and  practical  form.  There  is  perhaps 
no  similar  work  written  for  the  general  public 
thatcontains  suchacomplet^eliable  and  instruc- 
tive collection  of  data  upon  me  diseases  common 
to  the  race,  their  origins,  causes,  and  the  measures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarly ;  the  discussion  of 


the  question  of  disease  is  comprehensive,  masterly 
and  fully  abreast  with  the  latest  and  best  knowl- 
edge on  the  subject,  and  the  preventive  measures 
advised  are  accurate,  explicit  and  reliable.— 77ie 
American  Journal  of  the  Medical  Sciences,  April,  1884. 

This  is  a  book  that  will  surely  find  a  place  on  the 
table  of  every  progressive  physician.  To  the  medi- 
cal profession,  whose  duty  is  quite  as  much  to 
prevent  as  to  cure  disease  the  book  will  be  a  boon. 
— Boston  Medical  and  Surgical  Journal,  Marcli  6, '84. 

The  treatise  contains  a  vast  amount  of  solid,  val- 
uable hygienic  information.— il/edicaJ  and  Surgical 
Reporter,  Feb.  23, 1884. 


TSE  YEAB-BOOK  OF  TBEATMENT  FOB  1889. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine.    In  one  12mo.  volume  of  349  pages,  bound  in  limp  cloth,  $1.25.     Jv^t  ready. 

^*:^  For  special  commutations  with  periodicals  see  page  2. 

TME  YEAB-BOOK  OF  TBEATMENT  FOB  1887, 

Similar  to  above.     12mo.,  341  pages.    Limp  cloth,  $1.25. 


this  is  one  of  the  most  valuable  books  for  its 
price  which  is  published  in  this  or  any  coun- 
try. It  contains  a  summary  of  the  changes  in 
medical  practice,  the  new  remedies  introduced, 
and  the  experience  with  them  and  with  others 
which  have  been  longer  in  use,  during  the  year 
1887,  made  up  from  the  reading  and  observation 
of  a  number  of  very  capable  men.  The  classifica- 
tion is  according  to  diseases,  so  that  one  who  con- 


sults these  pages  can  obtain  in  a  few  minutes  an 
excellent  idea  of  the  present  status  of  therapeu- 
tics in  regard  to  any  given  ailment.  The  book 
also  has  a  good  index,  by  means  of  which  the 
reader  may  ascertain  the  diflferent  diseases  for 
which  any  particular  drug  has  been  used  during 
the  year  past. — Medical  and  Surgical  Reporter, 
April  14, 1888. 


TME  YEAB-BOOK  OF  TBEATMENT  FOB  1886. 

Similar  to  that  of  1887  above.     12mo.,  320  pages.    Limp  cloth,  $1.25. 

8CSBEIBEB,  DB.  JOSEPH. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  Walter  Mendelson,  M.  D.,  of  New  York.  In  one  handsome 
octavo  volume  of  274  pages,  with  117  fine  engravings.    Just  ready.    Cloth,  $2.75. 

This  is  a  work  abounding  in  common  sense,  a 
book  that  sweeps  away  a  great  deal  of  nonsense 
by  which  a  simple  matter  has  been  made  obscure, 
a  volume  that  ought  to  be  read  by  every  one  inter- 
ested in  modern  thera])eutics.     The  work  gives 


admirable  directions  for  the  employment  of  mas- 
sage, and  capital  descriptions  of  methodical  exer- 


cise, after  which  there  is  a  detailed  account  of  the 
results  of  treatment  of  different  diseases  by  these 
methods.  A  full  bibliography  adds  to  the  value  of 
the  volume,  which  canT)e  recommended  as  one  of 
the  best  on  the  subjects  with  which  it  deals. — 
Edinburgh  Medical  Journal,  April,  1888. 


STURGES'  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  Being  a  Guide  to 
the  Investigation  of  Disease.  In  one  handsome 
12mo.  volume  of  127  pages.    Cloth,  81.25. 

DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES.  By  N.  S.  Davis. 
M.  D.  Edited  by  Fbank  H.  Davis,  M.  D.  Second 
edition.    12mo.  287  pages.    Cloth,  81.75. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
320  pages.    Cloth,  $2.50. 


PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  paces.    Cloth,  82.00. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Conbie, 
M.  D.    1  vol.  8vo.,  pp.  603.     Cloth,  82.50. 

CHAMBERS'  MANITAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.    Cloth,  82.75. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  8vo.,  pp.  493.    Cloth,  $3.50. 


18         Lea  Brothers  &  Co.'s  Publications — Throat,  Liiings,  Heart. 


FLINT,  AUSTIN,  M.  D.,  Xi.  2>., 

Profeisor  of  the  iVinctpies  and  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  Y. 

A.  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis  of 
Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fourth  edition.  In  one 
handsome  royal  12mo.  volume  of  278  pages,  Avith  14  illustrations.    Cloth,  $1.75. 


The  original  work  done  by  Dr.  Flint  in  the  devel- 
opment of  the  art  of  physical  diagnosis  will  always 
make  this  manual  an  authority  on  this  subject. 
Among  all  the  works  issued  on  this  topic  during 
the  last  few  years,  none  exceeds  this  one  in  sim- 
plicity and  completeness.    The  fact  that  it  has 


passed  through  four  editions  attests  its  popularity. 
There  is  a  tendency  among  physical  diagnosti- 
cians to  make  altogether  too  many  varieties  of 
morbid  chest  sounds,  and  especially  of  rales.  The 
conciseness  of  Dr.  Flint's  Manual  is  one  of  its  chief 
advantages  — Medical  Record,  June  10, 1888. 


B7  THE  SAME  AUTHOR. 


A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.  Second  and 
revised  edition.    In  one  handsome  octavo  volume  of  591  pages.    Cloth,  $4.50. 

Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis ;  In  a  series  of  Clinical  Studies.    In  one  octavo  volume  of  442  pages.    Cloth,  $3.50. 

A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 

Diseases  of  the  Heart.     Second  revised  and  enlarged  edition.    In  one  octavo  volume 
of  550  pages,  with  a  plate.    Cloth,  $4. 

Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.    Cloth,  $1.38. 


BBOWKE,  LJENNOX,  F.  B.  C,  S.,  E,, 

Senior  Physician  to  the  Central  London  Throat  and  Ear  Hospital. 

A  Practical  Guide  to  Diseases  of  the  Throat  and  Nose,  including 
Associated  Affections  of  the  Ear.  With  120  illustrations  in  color,  and  200  en- 
gravings on  wood  designed  and  executed  by  the  Author.  New  (second)  and  enlarged 
edition.     In  one  imperial  octavo  volume  of  628  pages.     Cloth,  $6. 


Mr.  Browne's  book  can  be  recommended  to 
students  and  still  more  to  practitioners  as  a  clear, 
sound  and  practical  guide  to  the  diagnosis  and 
treatment  of  diseases  of  the  throat.  His  experi- 
ence is  not  only  large,  but  ripe,  and  he  gives  his 
readers  the  full  benefit  of  it.    A  particularly  praise- 


worthy feature  is  that  from  beginning  to  end  Mr. 
Browne,  whilst  giving  due  prominence  to  local 
measures,  never  fails  to  insist  on  the  necessity  of 
supplementing  these  by  proper  constitutional 
treatment. — London  Medical  Recorder,  May,  1888. 


SEILEB,  CABL,  M,  2)., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.  New  (third)  edition.  In  one  handsome  royal  12mo. 
volume  of  373  pages,  with  101  illustrations  and  2  colored  plates.   Cloth,  $2.25.    Just  ready. 


Few  medical  writers  surpass  this  author  in 
ability  to  make  his  meaning  perfectly  clear  In  a 
few  words,  and  in  discrimination  in  selection,  both 


of  topics  and  methods.  The  book  deserves  a  large 
sale,  especially  among  general  practitioners — Chi- 
cago Medical  Journal  and  Examiner,  April,  1889. 


GBOSS,  S.  D.,  M,D.,  LL.I>.,  D.CL.  Oxon.,  LL.I>.  Cantab, 

A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.    In  one 

octavo  volume  of  452  pages,  with  59  illustrations.    Cloth,  $2.75. 


COHEN,  J.  SOUS,  M,  2)., 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  the  Jefferson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Affections  of  the  Pharynx,  (Esophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustrations.  In 
one  very  handsome  octavo  volume.     Preparing. 


BBOADBENT,  W.  M.,  M.  D.,  F.  B.  C.  F,, 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary's  Hospital. 
The  Pulse.    In  one  12mo.  volume.   Preparing.    See  Series  of  Clinical  Manuals,  page  4. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND 
AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  $3.50. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.    In  1  vol.  8vo..  416  pp.     Cloth,  83.00. 

BLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 


valence in  various  Countries.  Second  and  revised 
edition.     In  one  12mo.  vol.,  pp.  158.    Cloth,  §1.25. 

SMITH  ON  CONSUMPTION  ;  its  Early  and  Reme- 
diable Stages.    1  vol.  8vo.,  pp.  253.    Cloth,  $2.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.  of  490 
pages.    Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  V/ith  an 
analysis  of  one  thousand  cases  to  exemplify  ita 
duration.   In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.50. 


Lea  Brothers  &  Co.'s  Publications — Nerv.  and  Ment.  Dis.,  etc.     19 


MOSS,  JAMES,  M.n.,  F.B.C.P.,  LL.D., 

Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary. 


A  Handbook  on  Diseases  of  the  Nervous    System.     In  one 

volume  of  725  pages,  with  184  illustrations.     Clotli,  $4.50 ;  leather,  $5.50. 

This  admirable  work  is  intended  for  students  of 
medicine  and  for  suchi  medical  men  as  have  no  time 
for  length)' treatises.  In  tlie  present  instance  the 
duty  of  arranging  the  vast  store  of  material  at  the 
disposal  of  the  author,  and  of  abridging  the  de- 
scription of  the  different  aspects  of  nervous  dis- 
eases, has  been  performed  vcith  singular  skill,  and 
the  result  is  a  concise  and  philosophical  guide  to 


octavo 


the  department  of  medicine  of  which  it  treats. 
Dr.  Ross  holds  such  a  high  scientific  position  that 
any  writings  which  bear  his  name  are  naturallv 
expected  to  liave  the  impress  of  a  powerful  intel- 
lect. In  every  part  this  handbook  merits  the 
highest  praise,  and  will  no  doubt  be  found  of  the 
greatest  valueto  the  student  as  well  as  to  the  prac- 
titioner.— Edinburgh  MedicalJournal,  Jan.  1887. 


MITCSBLL,  S,  WJEin,  M,  D., 

Physician  to  Orthopaedic  Hospital  and  the  Infirmary  for  Diseases  of  the  Nervous  System,  Phila.,  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  Especially  in  Women. 
Second  edition.     In  one  12mo.  volume  of  288  pages.     Cloth,  $1.75. 

No  work  in  ouc  language  develops  or  displays 
more  features  of  that  many-sided  affection,  hys- 


teria, or  gives  clearer  directions  for  its  differen- 
tiation, or  sounder  suggestions  relative  to  its 
general  management  and  treatment.  The  book 
IS  particularly  valuable  in  that  it  represents  in 
the  main  the  author's  own  clinical  studies,  which 
have  been  so  extensive  and  fruitful  as  to  give  iiis 


teachings  the  stamp  of  authority  all  over  the 
realm  of  medicine.  The  work,  although  written 
by  a  specialist,  has  no  exclusive  character,  and 
the  general  practitioner  above  all  others  will  find 
its  perusal  profitable,  since  it  deals  with  diseases 
which  he  frequently  encounters  and  must  essay 
to  treat. — A7nerican  Practitioner,  August,  1885. 


SAMIZTOW,  ALL  AW  McLANJE,  M.  J),, 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlaekweU's  Island,  N.  T. 
Nervous  Diseases ;  Their  Description  and  Treatment.     Second  edition,  thoroughly 
revised  and  rewritten.    In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 

characterized  this  book  as  the  best  of  its  kind  in 


When  the  first  edition  of  this  good  book  appeared 
we  gave  it  our  emphatic  endorsement,  and  the 
present  edition  enhances  our  appreciation  of  the 
book  and  its  author  as  a  safe  guide  to  students  of 
clinical  neurology.  One  of  the  best  and  most 
critical  of  English  neurologicaljournals,  Brain,  has 


any  language,  which  is  a  handsome  endorsement 
from  an  exalted  source.  The  improvements  in  the 
new  edition,  and  the  additions  to  it,  will  justify  its 
purchase  even  by  those  who  possess  the  old. — 
Alienist  and  Neurologist,  April,  1882. 


TVKB,  I>ANTEL  BLACK,  M.  D., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thoroughly  re^yised  and  rewritten.  In  one  8vo.  vol.  of  467  pp.,  with  2  col.  plates.   Cloth,  1 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 
amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomena  the  more  firmly 
has  he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  most  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 
commend  itself  to  every  thoughtful  understand- 
ing.— New  York  Medical  Journal,  September  6, 1884. 


CLOUSTOW,  TSOMAS  S.,  M.  D,,  F,  M.  C.  P.,  i.  M.  C,  S., 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Charles  F.  Folsom,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  handsome  octavo  volume  oi  541 
pages,  with  eight  lithographic  plates,  four  of  which  are  beautifully  colored.     Cloth,  $4. 


The  practitioner  as  well  as  the  student  will  ac- 
cept the  plain,  practical  teaching  of  the  author  as  a 
forward  step  in  the  literature  of  insanity.  It  is 
refreshing  to  find  a  physician  of  Dr.  Clouston's 
experience  and  high  reputation  fifing  the  bed- 
side notes  upon  which  his  experience  has  been 
founded  and  his  mature  judgment  established. 
Such  clinical  observations  cannot  but  be  useful  to 


the  general  practitioner  in  guiding  him  to  a  diag- 
nosis and  indicating  the  treatment,  especially  in 
many  obscure  and  cfoubtful  cases  of  mental  dis- 
ease. To  the  American  reader  Dr.  Folsom's  Ap- 
pendix adds  greatly  to  the  value  of  the  work,  and 
will  miiie  it  a  desirable  addition  to  every  library. 
— American  Psychological  Jownal,  July,  1884. 


108  pages. 


•.  Folsom's  Abstract  may  also  be  obtained  separately  in  one  octavo  volume  of 
Cloth,  $1.50. 


SAVAGE,  GEORGE  S,,  M,  D., 

Lecturer  on  Mental  Diseases  at  Cfuy's  Hospital,  London. 
Insanity  and  Allied   Neuroses,  Practical  and  Clinical.     In  one  12mo.  vol. 
of  551  pages,  with  18  illus.     Cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  4. 

BLAYFAIM,  W.  S,,  M,  D.,  F,  M.  C.  JP. 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.    In 

one  handsome  small  12mo.  volume  of  97  pages.     Cloth,  $1.00. 

Blandford  on  Insanity  and  its  Treatment:   Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.     In  one  very  handsome  octavo  volume. 

Jones'   Clinical   Observations   on   Functional    Nervous    Disorders. 
Second  American  Edition.     In  one  handsome  octavo  volume  of  340  pages.     Cloth,  $3.25. 


20 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


ASHJBCURST,  JOSN,  Jr.,  M,  D,, 

Professor  of  Clinical  Surgery,  Univ.  of  Penna.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

The  Principles  and  Practice  of  Surgery.  New  (fourth)  edition,  enlarged 
and  revised.  In  one  large  and  handsome  octavo  volume  of  1114  pages,  with  597  illustra- 
tions.    Cloth,  $6 ;  leather,  $7. 


As  with  Erichsen  so  with  Ashhurst,  its  position 
in  professional  favor  is  established,  and  one  has 
now  but  to  notice  the  changes,  if  any,  in  theory 
and  practice,  that  are  apparent  in  the  present 
as  compared  with  the  preceding  edition,  published 
three  years  ago.  The  work  has  been  brought  well 
up  to  date,  and  is  larger  and  better  illustrated  than 
before,  and  its  author  may  rest  assured  that  it  will 
certainly  have  a  "continuance  of  the  favor  with 
which  it  has  heretofore  been  received." — The 
American  Journal  of  the  Medical  Sciences,  Jan.  1886. 


Every  advance  in  surgery  worth  notice,  chroni- 
cled in  recent  literature,  has  been  suitably  recog- 
nized and  noted  in  its  proper  place.  Suffice  It  fo 
say,  we  regard  Ashhurst's  Surgery,  as  now  pre- 
sented in  the  fourth  edition,  as  the  best  single 
volume  on  surgery  published  in  the  English  lan- 
guage, valuable  alike  to  the  student  and  the  prac- 
titioner, to  the  one  as  a  text-book,  to  the  other  as 
a  manual  of  practical  surgery.  With  pleasure  we 
give  this  volume  our  endorsement  in  full. — New 
Orleans  Medical  and  Surgical  Journal,  Jan.,  1886. 


GJROSS,  S,  n,,  M,  n,,  LL,  D,,  D.  a  L.  Oxon,,  LL,  n. 
Cantab., 

Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System  of  Surgery :    Pathological,   Diagnostic,  Therapeutic  and  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.     In  two  large  and  beautifully- 
printed  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings; 
Strongly  bound  in  leather,  raised  bands,  $15, 

Dr.  Gross'  System  of  Surgery  has  long  been  the 
standard  work  on  that  subject  for  students  and 
practitioners. — London  Lancet,  May  10, 1884. 
The  work  as  a  whole  needs  no  commendation 


Many  years  ago  it  earned  for  itself  the  enviable 
reputation  of  the  leading  American  work  on  sur- 
gery, and  it  is  still  capable  of  maintaining  that 
standard.  A  consideraole  amount  of  new  material 
has  been  introduced,  and  altogether  the  distin- 
guished author  has  reason  to  be  satisfied  that  he 
has  placed  the  work  fully  abreast  of  the  state  of 
our  knowledge.— ilfed.  Becord,  Nov.  18, 1882. 


His  System  of  Surgery,  which,  since  its  first  edi- 
tion in  1859,  nas  been  a  standard  work  in  this 


country  as  well  as  in  America,  in  "the  whole 
domain  of  surgery,"  tells  how  earaest  and  labori- 
ous and  wise  a  surgeon  he  was.  how  thoroughly 
he  appreciated  the  work  done  by  men  in  other 
countries,  and  how  much  he  contributed  to  pro- 
mote the  science  and  practice  of  surgery  in  his 
own.  There  has  been  no  man  to  whom  America 
is  so  much  indebted  in  this  respect  as  the  Nestor 
of  snTgery.— British  Medical  Journal,  May  10, 1884. 


DJRUITT,  BOBBItT,  31.  B.  C.  S.,  etc. 

Manual  of  Modern  Surgery.  Twelfth  edition,  thoroughly  revised  by  Stan- 
ley Boyd,  M.  B.,  B.  S.,  F.  E.  C.  S.  In  one  8vo.  volume  of  965  pages,  with  373  illustra- 
tions.   Cloth,  $4 ;  leather,  $5. 


It  is  essentially  a  new  book,  rewritten  from  be- 
ginning to  end.  The  editor  has  brought  his  work 
up  to  the  lat«st  date,  and  nearly  every  subject  on 
wnich  the  student  and  practitioner  would  desire 
to  consult  a  surgical  volume,  has  found  its  place 
here.  The  volume  closes  with  about  twenty  pages 
of  formulee  covering  a  broad  range  of  practical 
therapeutics.  Th(  student  will  find  that  the  new 
Druitt  is  to  this  generation  what  the  old  one  was 
to  the  former,  and  no  higher  praise  need  be 
accorded  to  any  volume. — North  Carolina  Medical 
Journal,  October,  1887. 


Druitt's  Surgery  has  been  an  exceedingly  popu- 
lar work  in  the  profession.  It  is  stated  that  50,000 
copies  have  been  sold  in  England,  while  in  the 
United  States,  ever  since  its  first  issue,  it  has  been 
used  as  a  text-book  to  a  very  large  extent.  Dur- 
ing the  late  war  in  this  country  it  was  so  highly 
appreciated  that  a  copy  W£ks  issued  by  the  Govern- 
ment to  each  surgeon.  The  present  edition,  while 
it  has  the  same  features  peculiar  to  the  work  at 
first,  embodies  all  recent  discoveries  in  surgery, 
and  is  fully  up  to  the  times.  Cincinnati  3Ieaieal 
News,  September,  1887. 


BALL,  CBLABLBS  B.,  M.  Ch.,  Bub.,  F.  B.  C.  S.  E., 

Surgeon  and  Teacher  at  Sir  P.  Dun's  Hospital,  Dublin. 

Diseases  of  the  Rectum  and  Anus.  In  one  12mo.  volume  of  417  pages, 
with  54  engravings  and  4  colored  plates.  Cloth,  $2.25.  Just  ready.  See  Series  of  Clinical 
Manuals,  page  4. 

It  is  a  pleasure  to  read  an  exhaustive  and  well- 
arranged  book,  such  as  the  one  before  us.  It 
covers  all  the  ground,  and  yet  is  written  in  a  terse 
and  concise  style  that  makes  it  exceedingly  good 
reading.  The  work  is  far  in  advance  of  the  ordi- 
nary text-book  on  this  specialty.  It  is  very  com- 
plete, and  the  matter  is  all  of  practical  importance 
and  well  arranged.  The  writer  has  done  for  rectal 
surgery  what  Treves  in  the  companion  volume 


has  done  for  intestinal  obstruction,  and  both 
works  are  alike  creditable. — N.  Y.  Medical  Journal, 
Jan.  28, 1888. 

A  capital  book  in  a  capital  series  of  clinical 
manuals.  Thoroughly  practical,  it  is  both  compre- 
hensive and  condensed  and  the  possessor  of  it  will 
find  but  little  use  for  any  more  extended  work  on 
the  subject.  Mr.  Ball  is  a  most  sound  surgeon.— 
The  Medical  News,  Feb.  4, 1888. 


GIBNJEY,  V.  JP.,  M.  D., 

Surgeon  to  the  Orthopaedic  Hospital,  New  York,  etc. 
Orthopaedic  Surgery.    For  the  use  of  Practitioners  and  Students.    In  one  hand- 
some octavo  volume,  profusely  illustrated.     Preparing. 

BOBJEBTS,  J.  B.,  M.  D.,  and  MOBTOJ^,  T.  S.  K.,  M.  X>., 

Professor  of  Anatomy  and  Surgery  in  the  Adjunct  Professor  of  Operative  Surgery  in  the 

Philadelphia\Polyclimc.  Philadelphia  Polyclinic. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Students 
and  Practitioners  of  ^ledicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  about 
500  pages,  with  many  illustrations.    Preparing. 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


21 


EHICHSEN,  JOHN  JE.,  F,  B,  S.,  F,  JR.  C.  S,, 

Professor  of  Surgery  in  University  College,  London,  etc. 

The  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Operations.  From  the  eighth  and  enlarged  English  edition.  In  two  large  and 
beautiful    octavo    volumes  of  2316    pages,    illustrated   with  984  engravings  on  wood. 


Cloth,  $9;  leather,  raised  bands,  |11 

We  have  always  regarded  "The  Science  and 
Art  of  Surgery"  as  one  of  the  best  surgical  text- 
books in  the  English  language,  and  this  eighth 
edition  only  confirms  our  previous  opinion.  We 
take  great  pleasure  in  cordially  commending  it  to 
our  readers. —  The  Medical  Neios,  April  11, 1885. 

For  many  years  this  classic  work  has  been 
made  by  preference  of  teachers  the  principal 
text-book  on  surgery  for  medical  studenis,  while 
through  translations  into  the  leading  continental 
languages  it  may  be  said  to  guide  the  surgical 
teachings  of  the  civilized  world.  No  excellence 
of  the  former  edition  has  been  dropped  and  no 
discovery,   device   or   improvement    which    has 


marked  the  progress  of  surgery  during  the  last 
decade  has  been  omitted.  The  illustrations  are 
many  and  executed  in  the  highest  style  of  art. 
— Louisville  Medical  News,  Feb.  14,  1885. 

We  cannot  speak  too  highly  of  this  excellent 
work.  It  represents  the  most  ad  vanced  and  settled 
views  in  regard  to  the  science  of  surgery,  and  will 
ever  be  found  a  faithful  guide  and  counsellor  in 
practice. — Canada  Lancet,  May,  1885. 

It  appears  simultaneously  in  England,  America, 
Spain  and  Italy,  and  is  too  well  known  as  a  safe 
guide  and  familiar  friend  to  need  further  com- 
ment.—iVew  York  Medical  Journal,  March  28, 1885. 


BBTAJSTT,  THOMAS,  F,  B.  C.  S,, 

Surgeon  and  Lecturer  on  Surgery  at  Gfuy^s  Hospital,  London.   • 
The  Practice  of  Surgery.     Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.     In  one  large  and  very  handsome  imperial  octavo  volume  of  1040  pages,  with 
727  illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 


The  fourth  edition  of  this  work  is  fully  abreast 
of  the  times.  The  author  handles  his  subjects 
with  that  degree  of  judgment  and  skill  which  is 
attained  by  years  of  patient  toil  and  varied  ex- 
perience. The  present  edition  is  a  thorough  re- 
vision of  those  which  preceded  it,  with  much  new 
matter  added.  His  diction  is  so  graceful  and 
logical,  and  hia  explanations  are  so  lucid,  as  to 
place  the  work  among  the  highest  order  of  text- 
books for  the  medical  student.  Almost  every 
topic  in  surgery  is  presented  in  such  a  form  as  to 


enable  the  busy  practitioner  to  review  any  subject 
in  every-day  practice  in  a  short  time.  No  time  is 
lost  with  useless  theories  or  superfluous  verbiage. 
In  short,  the  work  is  eminently  clear,  logical  and 
practical. — Chicago  Medical  Journal  and  Examiner, 
April,  1886. 

This  book  is  essentially  what  it  purports  to  be, 
viz.:  a  manual  for  the  practice  of  surgery.  It  is 
peculiarly  wel!  fitted  for  the  student  or  busy  general 
practitioner.— TAe  Medical  News,  August  15, 1885. 


TBEVES,  FBEDBBICK,  F,  M.  C.  S., 

Eunterian  Professor  at  the  Royal  College  of  Surgeons  of  England. 
A  Manual   of  Surgery.  _  In  Treatises  by  Various  Authors.     In  three  12mo. 
volumes,  containing  1866  pages,  with  213  engravings.     Price  per  volume,  cloth,  $2.     See 
Students'  Series  of  Manuals,  page  4. 

the  salient  points  and  the  beginnings  of  new  sub- 
jects are  always  printed  in  extra-heavy  type,  so 
that  a  person  may  find  whatever  information  he 
may  be  in  need  of  at  a  moment's  glance. — Oin- 
cinnati  Lancet-Clinic,  August  21, 1886. 


We  have  here  the  opinions  of  thirty-three 
authors,  in  an  encyclopsedic  form  for  easy  and 
ready  reference.  The  three  volumes  embrace 
every  variety  of  surgical  aflfections  likely  to  be 
met  with,  the  paragraphs  are  short  and  pithy,  and 


MABSS,  MOWABD,  F,  JR,  O.  S,, 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London. 
Diseases  of  the  Joints.     In  one  12mo.  volume  of  468  pages,  with  64  woodcuts 
and  a  colored  plate.    Cloth,  $2.00.    See  Series  of  Clinical  Mamuals,  page  4. 

BUTLIN,  SFJVBT  T.,  F.  B.  C.  S., 

Assistant  Surgeon  to  St.  Bartholomew's  Hospital,  London. 
Diseases    of  the   Tongue.     In  one  12mo.  volume  of  456  pages,  with  8  colored 
plates  and  3  woodcuts.     Cloth,  $3.50.     See  Series  of  Clinical  Manuals,  page  4. 

The  language  of  the  text  is  clear  and  concise. 
The  author  has  aimed  to  state  facts  rather  than  to 
express  opinions,  and  has  compressed  within  the 
compass  of  this  small  volume  tne  pathology,  etiol- 
ogy, etc.,  of  diseases  of  the  tongue  that  are  incon- 


veniently scattered  through  general  works  on  sur- 
gery and  the  practice  of  medicine.  The  physician 
and  surgeon  will  appreciate  its  value  as  an  aid  and 
gm&e.—Physician  and  Surgeon,  Sept.  1886. 


TBEVES,  FBEDEBICK,  F.  B,  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  the  Loixdon  Hospital. 

Intestinal  Obstruction.    In  one  pocket-size  12mo.  volume  of  522  pages,  with  60 


illustrations.  Limp  cloth,  blue  edges,  $2.00. 

A  standard  work  on  a  subject  that  has  not  been 
so  comprehensively  treated  by  any  contemporary 
English  writer.  Its  completeness  renders  a  full 
review  difficult,  since  every  chapter  deserves  mi- 
nute attention,  and  it  is  impossible  to  do  thorough 


See  Series  of  Clinical  Manuals,  page  4. 
justice  to  the  author  in  a  few  paragraphs.  Intes- 
tinal Obstruction  is  a  work  that  will  prove  of 
equal  value  to  the  practitioner,  the  student,  the 
pathologist,  the  physician  and  the  operating  sur- 
geon.—£ri«usA  Medical  Journal,  Jan.  31, 1885. 


GOUZJD,  A,  BEABCE,  M.  S.,  M,  B,,  F.  B,  C.  S., 

Assistant  Surgeon  to  Middlesex  Hospital. 

Elements  of  Surgical  Diagnosis.    In  one  pocket-size  12mo.  volume  of  589 
pages.     Cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  4. 


PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  John  Neill,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.    Cloth,  83.75. 

MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  edition.  In 


one  8vo.  vol.  of  638  pages,  with  340  illustrations. 
Cloth,  33.75. 
MILLER'S  PRACTICE  OP  SURGERY.     Fourth 
and  revised  American  edition.    In  one  large  8vo. 
vol.  of  682  pp.,  with  364  Illustrations.    Cloth,  $3.75» 


22      Lea  Brothers  &  Co.'s  Pttblioations — Surgery,  Frac.,  Dlsloc. 


SMITH,  STEPHEN,  M,  D., 

ProfcsHor  of  Clhiical  /SiirQtn/  in  the  Universih/  of  the  dtf/  of  New  York. 

The  Principles  and  Practice  of  Operative  SurgexTr.  New  (second)  and 
thoronglily  revised  edition.  In  one  very  liandsorae  octavo  volume  of  892  pages,  with 
1005  illustrations.     Cloth,  $4.00;  leather,  $5.00, 


This  excellent  and  very  valuable  hook  is  one  of 
the  most  satisfactory  works  on  modern  operative 
surgery  yet  published.  Its  author  and  publisher 
have  spared  no  pains  to  make  it  as  far  as  possible 
an  ideal,  and  their  efforts  have  given  it  a  position 
prominent  among  the  recent  works  in  this  depart- 
ment of  surgery.  The  book  is  a  compendium  for 
the  modern  surgeon.  The  present,  the  only  revised 
edition  since  1879,  presents  many  changes  from 
the  original  manual.  The  volume  is  much  en- 
larged, and  the  text  has  been  thoroughly  revised, 
60  as  to  give  the  most  improved  methods  in  asep- 


tic surgery,  and  the  latest  instruments  known  foi 
operative  work.  Itcan  be  truly  said  thatas  ahand- 
book  for  the  student,  acompanion  forthe  surgeon, 
and  even  as  a  hook  of  reference  for  the  physician 
not  especially  engaged  in  the  practice  or  surgery, 
this  volume  will  long  hold  a  most  conspicuous 
place,  and  seldom  will  its  readers,  no  matter  how 
unusual  the  sul>ject, consult  its  pages  in  vain.  Its 
compact  form,  excellent  print,  numerous  illustra- 
tions, and  especially  its  decidedly  practical  char- 
acter, all  combine  to  commend  it. — Boston  Medical 
and  Surgical  Journal,  May  10,  1888. 


HOLMES,  TI3IOTHY,  M,  A., 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  JTospital,  London. 

A  Treatise  on  Surgery ;  Its  Principles  and  Practice.    New  American 

from  the  fifth  English  edition,  edited  by  T.  Pickering  Pick,  F.  K.  C.  S.,  Surgeon  and 
Lecturer  on  Surgery  at  St.  George's  Hospital,  London.  In  one  octavo  volume  of  997 
pages,  with.  428  illustrations.     Cloth,  $6 ;  leather,  $7.     Jtcst  ready. 


To  the  younger  members  of  the  profession  and 
toothers  not  acquainted  with  the  book  and  its 
merits,  we  take  pleasure  in  recommending  it  as  a 
surgery  complete,  thorough,  well-written,  fully 
illustrated,  modern,  a  work  sufficiently  volumi- 
nous for  the  surgeon  specialist,  adequately  concise 


for  the  general  practitioner,  teaching  those  things 
that  are  necessary  to  be  known  for  tne  successful 
prosecution  of  the  physician's  career,  imparting 
nothing  that  in  our  present  knowledge  is  consid- 
ered unsafe,  unscientific  or  inexpedient. — Pacific 
Medical  Journal,  July,  1889. 


HOLMES,  TIMOTHY,  M.  A,, 

Surgeon  and  Lecturer  on  Surgerv  at  St.  George's  Hospital,  London. 

A  System  of  Surgery;  Theoretical  and  Practical.  IN  TREATISES  BY 
VARIOUS  AUTHORS.  American  edition,  thoroughly  revised  and  re-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospitals, 
Philadelphia,  assisted  by  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons. 
Li  three  large  imperial  octavo  volumes  containing  3137  double-columned  pages,  with 
979  illustrations  on  wood  and  13  lithographic  plates,  beautifully  colored.  Price  per 
set,  cloth,  $18.00;  leather,  $21.00.     Sold  only  by  syhscription. 

STIMSON,  LEWIS  A.,  B,  A.,  M,  D., 

Surgeon  to  the  Presbyterian  and  Bellevue  Hospitals,  Professor  of  Clinical  Surgery  in  the  Medical 
Faculty  of  Univ.  of  City  of  N.   Y.,  Corresponding  Member  of  the  Societe  de  Chirurgie  of  Paris. 
A  Manual  of  Operative  Surgery.     New  (second)  edition.    In  one  very  hand- 
some royal  12mo.  volume  of  503  pages,  with  342  illustrations.     Cloth,  $2.50. 
There  is  always  room  for  a  good  book,  so  that 

while  many  works  on  operative  surgery  must  be 

considered  superfluous,  that  of  Dr.  Stimson  has 

held  its  own.    The  author  knows  the  difficult  art 

of  condensation.      Thus  the  manual  serves  as  a 

work  of   reference,  and  at  the  same   time  as  a 

handy  guide.    It  teaches  what  it  professes,  the 

steps  of  operations.    In  this  edition  Dr.  Stimson 

has  sought  to  indicate  the  changes  that  have  been 


effected  in  operative  methods  and  procedures  by 
the  antiseptic  system,  and  has  added  an  account 
of  many  new  operations  and  variations  in  the 
steps  of  older  operations.  We  do  not  desire  to 
extol  this  manual  above  many  excellent  standard 
British  publications  of  the  same  class,  still  we  be- 
lieve that  it  contains  much  that  is  worthy  of  imi- 
tation.— British  Medical  Journal,  Jan.  22, 1887. 


By  the  same  Author. 
A  Treatise  on  Fractures  and  Dislocations.    In  two  handsome  octavo  vol- 
umes.    Vol.  I.,  Fractures,  582  pages,  360  beautiful  illustrations.    Vol.  II.,  Disloca- 
tions, 540  pages,  with  163  illustrations.     Complete  work  jxist  ready,  cloth,  $5.50 ;  leather, 
$7.50.     Either  volume  separately,  cloth,  $3.00;   leather,  $4.00. 


The  appearance  of  the  second  volume  marks  the 
completion  of  the  author's  original  plan  of  prepar- 
ing a  work  which  should  present  in  the  fullest 
manner  all  that  is  known  on  the  cognate  subjects 
of  Fractures  and  Dislocations.  The  volume  on 
Fracturesassumedatoncetfheposition  of  authority 
on  the  subject,  and  its  companion  on  Dislocations 
will  no  doubt  be  similarly  received.  The  closing 
volume  of  Dr.  Stimson's  work  exhibits  the  surgery  | 


of  Dislocations  as  it  is  taught  and  practised  by  the 
most  eminent  surgeons  of  the  present  time.  Con- 
taining the  results  of  such  extended  researches  It 
must  for  a  long  time  be  regarded  as  an  authority 
on  all  subjects  pertaining  to  dislocations.  Every 
practitioner  of  surgery  will  feel  it  incumbent  on 
nim  to  have  it  for  constant  reference. — Cincinnati 
Medical  News,  May,  1888. 


HAMILTON,  FRANK  H.,  M.  D.,  LL.  2)., 

Surgeon  to  Bellevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  Seventh  edition 
thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998 
pages,  with  379  illustrations.     Cloth,  $5.50:  leather,  $6.50. 


This  book  is  without  a  rival  in  any  language.  It 
is  essentially  a  practical  treatise,  and  it  gathers 
within  its  covers  almost  everything  valuable  that 
has  been  written  about  fractures  and  dislocations. 
The  principles  and  methods  of  treatment  are  very 


fully  given.  The  book  is  so  well  known  that  it  does 
not  require  any  lengthened  review.  We  can  only 
say  that  it  is  still  unapproached  as  a  treatise. — 
The  Dublin  Journal  of  Medical  Science,  Feb.  1886. 


I'ICK,  T,  PICKERING,  F.  B,  C,  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

Fractures  and  Dislocations.     In  one  12mo.  volume  of  530  pages,  with  9S 

illustrations.     Limp  cloth,  $2.00.     See  Series  of  Qinical  Manimls,  page  4. 


Lea  Brothers  &  Co.'s  Publications — Otol.,  Ophtlial. 


23 


BVRNBTT,  C HAULMS  II.,  A.  31.,  31.  2>., 

ProfcjiS'fr  of  Otology  in  the  Philaiielphin  Polyclinic;  Prcsiilcnt  of  the  American  OtoUigical  Society. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Pmctical  Treatise 
for  the  i!se  of  Mnlical  Htiiilents  and  Practitioners.  Second  editifin.  In  one  liandsf)nie 
octavo  volume  of  oSU  pages,  with  107  ilhistrations.   Cloth,  $4.00;  leather,  $5.00. 

We  note  with  pleasure  the  appearance  of  R  second  ]  rnrripd  out,  and  much  new  matter  added.  Dr. 
edition  of  tliin  vaUiahle  work.  When  it  first  came  |  Hiirnett's  work  must  he  re);ardcd  as  a  very  vahia- 
OUt  it  was  accepted  hy  the  profession  as  one  of  1  hie    contribution    to   aural   surgery,   not  only   oi> 


the  standard  works  on  modern  aural  surgery 
the  Knglish  lanKuaxc;  and  in  his  secoml  edition 
I>r.  Burnett  ha.s  fully  maintained  his  reputation, 
for  the  hook  is  replete  with  valuable  information 
and  sui<xestions.     The  revision  has  been  carefully 


account  of  its  comprehen.siveness,  but  because  it 
contains  the  results  of  the  careful  personal  observa- 
tion and  experience  of  thiseminentaural  HurKeon, 
— London  Lancet,  Feb.  iil.  Ia85. 


POLFTZEB,  A1JA3I, 

Itnjierinl-Iioynl  Prof,  of  Aurnl  Therap.  in  the  Univ.  of  Vienna. 

A  Text-Book  of  the  Ear  and  its  Diseases.  Translated,  at  the  Author's  re- 
quest, l)y  James  Patterson  Cassells,  M.  D.,  M.  K.  C  S.  In  one  handsome  octavo  vol- 
ume of  800  i)ages,  with  257  original  illustrations.     Cloth,  $5.50. 

The  whole  work  can  be  recommended  aa  a  reli-  I  the  practitioner  in  his  treatment. — Boston  Medical} 
able  guide  to  the  student,  and  an  efficient  aid   to  |  and  Surgical  Journnl,  June  7,  1883. 

JULEB,  HENRY  E.,  F.  R.  C.  S., 

Senior  Ass't  Surgeon,  Koyal  Westminster  Ophthalmic  Hosp. ;  laie  Clinical  Ass'l,  Moorjtelds,  London, 

A  Handbook  of  Ophthalmic  Science  and  Practice.  In  one  handsome 
octavo  volume  of  4(50  pages,  with  125  woodcuts,  27  colored  plates,  selections  from  the 
Test-tvpes  of  Jaeger  and  Snellen,  and  Holmgren's  Color-blindness  Test.  Cloth,  $4.50 ; 
leathe'r,  $5.50. 


It  presents  to  the  student  concise  descriptions 
and  typical  illu.strations  of  all  important  eyeaffec- 
tions,  placed  in  juxtaposition,  so  na  to  be  grasped 
at  a  glance  Beyond  a  doubt  it  is  the  best  illus- 
trated handbook  of  ophthalmic  science  which  has 
ever  appeared.    Then,  what  is  still  better,  these 


illustrations  are  nearly  all  original.  We  have  ex- 
amined this  entire  work  with  great  care,  and  it 
represents  the  commonly  accepted  views  of  ad- 
vanced ophthalmologists.  We  can  most  heartily 
commena  this  book  to  all  medical  students,  prac- 
titioners and  specialists.— X»e^/oi<  Lancet,  Jan.  '85. 


NETTLESHIB,  EDWARD,  F.  R.  C.  S., 

Ophthalmic  Surg,  and  Led.  on  Ophth.  Surg,  at  St.  Thovuis'  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  New  (third)  edition,  thor- 
oughly revised.  With  a  chapter  on  the  Detection  of  Color-Blindness,  by  William 
Thomson,  M.  D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical  College.  In  one 
12mo.  volume  of  479  pages,  with  164  illust.,  test-types  and  formulae.   Cloth,  $2. 


The  extent  of  the  sale  of  this  now  accepted 
authoritj'  has  conclusively  shown  that  its  claim  for 
favor  was  not  an  imaginary  one.  The  introductory 
chapter  on  optical  outlines  is  a  wonderfully  clear 
statement  of  the  principles  involved.  The  writer's 
decision  of  character  has  fully  impressed  hie  pro- 
duction, and  this  is  nowhere  more  apparent  tnan 


in  the  chapter  devoted  to  operations.  A  very 
important  partof  the  work  to  general  practitioners 
Is  that  embraced  in  the  consideration  of  eye  dis- 
eases in  relation  to  general  diseases  and  condi- 
tions. The  arrangement  of  the  remedies  employed 
into  a  formulary  is  adopted,  and  it  contains  much 
useful  knowledge. — South.  Practitioner,  Dec.  1887. 


XORRIS,  W3I.  F.,  M.  D.,  and  OLIVER,  CHAS.  A.,  31.  D. 

Clin.  Prof,  of  Ophthalmology  in  Univ.  of  Pa. 
A  Text-Book  of  Ophthalmology.     In  one  octavo  volume  of  about  500  pages, 
with  illustrations.     Preparing. 

CARTER,  R.  BRJJIJENELL,  &  FROST,  W.ADA3IS. 

F.  R.  C.  S.,  F.  R.  C.  S., 

Assistant  Ophthalmic  Surgeon  to  and  Joint 
Lecturer  on  Ofihthalmtc  Surgery  at  St. 
George's  UnspUal,  London. 


Ophthalmic  Surgeon  to  and  Lecturer  on  Oph- 
thalmic Surgery  at  St.  Oeorge's  Hospital, 
London. 


Ophthalmic  Surgery.  In  one  12mo.  volume  of  550  pages,  with  91  woodcuts, 
color  blindness  test,  test-types  and  dots  and  appendix  of  furmulte.  Cloth,  $2.25.  See 
Series  of  Clinical  Manuals,  page  4. 

WELLS,  J.  SOELBERG,  F.  R.  C.  S., 

Professor  of  Ophthalmology  in  King's  College  Hospital,  London,  etc. 

A  Treatise  on  Diseases  of  the  Eye.  New  (liftli)  American  from  the  third 
London  edition.     In  one  large  octavo  volume.     Preparing. 

BROWNE,  EDGARA^, 

Surgeon  to  the  Liverpool  Eye  aiui  Ear  Infirmary  and  to  the  Dispensary  for  Skin  Diseases. 

How  to  Use  the  Ophthalmoscope.  Being  Elementary  Instructions  in  Oph- 
thalmoscopy, arranged  for  the  use  of  Students.  lu  one  small  royal  12mo.  volume  of  116 
pages,  with  35  illustrations.     Cloth,  $1.00. 

LAURENCE  AND   MOON'S  HANDV  BOOK  OF    LAWSON  ON  INJURIES  TO  THE  EYE,  ORBIT 
OPHTHALMIC  SURGERY,  for  the  use  of  Prac-  !      AND  EYELIDS:  Their  Immediate  and  Remote 
titioners.    Second  edition.    In  one  octavo  vol-.      Effects.    8  vo.,  404  pp.,92  illua.    C)oib,$3.5U. 
ume  of  227  pages,  with  65  illus.    Cloth,  92.76.      I 


24     Lea  Brothers  &  Co.'s  Publications — Uriii.  Dis.,  Deutistry,  etc. 


ROBERTS,  WILLIAM,  31.  J>., 

Lecturer  ou  Medicine  i»i  the  Manchester  iSchnol  of  Mettieine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Fourth  American  from  tlie  fourth  London  etlition.  In  one  hand- 
some octavo  volume  of  609  p:iges,  with  81  illustrations.     Cloth,  $3.50. 


It  may  be  said  to  be  the  best  book  In  print  on  the 
subject  of  which  it  treats. —  The  American  Journal 
of  the  Medical  Sciences,  Jan.  1886. 

The  peculiar  value  and  finish  of  the  book  are  In 
a  measure  derived  from  its  resolute  maintenance 
of  a  clinical  and  practical  character.  It  is  an  un- 
rivalled exposition  of  everything  which  relates 
directly  or  indirectly  to  the  diagnosis,  prognosis 
and  treatment  of  urinary  diseases,  and  possesses 
a  completeness  not  found  elsewhere  in  our  lan- 


guage In  its  account  of  the  different  affectionB. — 
The  Manchester  Medical  Chronicle,  July,  ISS.'J. 

The  value  of  this  treatise  as  a  guide  oook  to  the 
physician  in  daily  practice  can  hardly  be  over- 
estimated. That  It  18  fully  up  to  the  level  of  our 
present  knowledge  is  a  fact  reflecting  grfat  credit 
upon  Dr.  Roberts,  who  has  a  wide  reputation  as  a 
busy  practitioner. —  The  Medical  Record,  July  31, 
1886. 


JPURDT,   CHARLES  TF.,  M,  Z>.,  CMcar/o. 

Bright's  Disease  and  Allied  Affections  of  the  Kidneys.    In  one  octavo 
volume  of  288  pages,  with  illustrations.    Cloth,  $2. 

The  object  of  this  work  is  to  "furnish  a  system- 
atic, practical  and  concise  description  of  the 
Sathoiogy  and  treatment  of  the  chief  organic 
iseases  of  the  kidney  associated  with  albuminu- 
ria, whicli  shall  represent  the  most  recent  ad- 
vances in  our  knowledge  on  these  subjects  ;"  and 
this  definition  of  the  object  is  a  fair  description  of 
the  book.    The  work  is  a  useful  one,  giving  in  a 


short  space  the  theories,  facts  and  treatments,  and 
going  more  fully  into  their  later  developments. 
On  treatment  the  writer  is  particularly  strong, 
steering  clear  of  generalities,  and  seldom  omit- 
ting, what  text-booKs  usually  do,  the  unimportant 
items  which  are  ah  important  to  the  general  prac- 
titioner.—TAe  Manchester  Medical  Chronicle,  Oct 
188G. 


MORRIS,  SENRY,  M,  B.,  F,  R,  C,  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 


Surgical  Diseases  of  the  Kidney. 

woodcuts,  and  6  colored  plates.  Limp  cloth,  ^ 
In  this  manual  we  have  a  distinct  addition  to  I 
surgical  literature,  which  gives  information  not 
elsewhere  to  be  met  with  in  a  single  work.     Such 
a  book  was  distinctly  required,  and  Mr.  Morris 
has  very  diligently  and  ably  performed  the  task  | 


In  one  12mo.  volume  of  554  pages,  with  40 
)2.25.     See  Series  of  Clinical  Manuals,  page  4. 

he  took  in  hand.  It  is  a  full  and  trustworthy 
book  of  reference,  both  for  students  and  prac- 
titioners in  search  of  guidance.  The  illustrations 
in  the  text  and  the  chromo-lithographs  are  beau- 
tifully executed.— r/jel/ondo/t  Lancet,  Feb.  26, 1886. 


See  Series 


LUCAS,  CLEMEWT,  M,  B.,  B,  S,,  F.  R.  C.  S., 

Senior  Assistant  Surgeon  to  Ouy^s  Hospital,  London. 
Diseases   of  the   Urethra.      In  one   12mo.  volume.     Preparing, 
of  Clinical  Manuals,  page  4. ^^ 

TH03IFS0N,  SIR  LLENRY, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  CoUege  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.    In  one  Svo.  volume  of  203  pp.,  with  25  illustrations.    Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Fistulas.    From  the  third  English  edition.    In  one  octavo  volume  of  359 
pages,  with  47  cuts  and  3  plates.    Cloth,  $3.50. 

TSE  AMERICAN  SYSTEM  OF  DENTISTRY, 

In  Treatises  by  Various  Authors.  Edited  by  Wilbur  F.  Litch,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  and  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  con- 
taining 3160  pages,  with  1863  illustrations  and  9  full  page  plates.  Per  volume,  cloth,  $6 ; 
leather,  $7 ;  half  Morocco,  gilt  top,  $8.  The  complete  work  is  now  ready.  For  sale  by 
svhscription  only. 


As  an  encyclopaedia  of  Dentistry  it  has  no  su- 
perior. It  should  form  a  part  of  every  dentist's 
library,  as  the  information  it  contains  is  of  the 
greatest  value  to  all  engaged  in  the  practice  of 
dentistry. — American  Jour.  Dent.  Set.,  Sept.  1886. 

A  grand  system,  big  enough  and  good  enough 
and  handsome  enough  for  a  monument  (which 


doubtless  it  is),  to  mark  an  epoch  in  the  history  of 
dentistry.  Dentists  will  be  satisfied  with  it  and 
proud  of  it — they  must.  It  is  sure  to  be  precisely 
what  the  student  needs  to  put  him  and  keep  him 
In  the  ri^ht  track,  while  tne  profession  at  large 
will  receive  incalculable  benefit  from  ii.—Odonta- 
graphic  Journal,  Jan.  1887. 


COLEMAN,  A,,  L,  R,  C,  F,,  F,  R.  C.  S.,  Exam.  L.  D.  S., 

Senior  Dent.  Surg,  and  Led.  on  Dent.  Surg,  at  St.  Bartholomew's  Hasp,  and  the  Dent.  Hasp.,  London. 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  Stellwagen,  M.  A.,  M.  D., 
D.  D.  S.,  Prof,  of  Physiology  in  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.     Cloth,  $3.25. 

It  should  be  in  the  possession  of  every  practi- 
tioner in  this  country.  The  part  devoted  to  first 
and  second  dentition  and  irregularities  in  the  per- 
manent teeth  is  fully  worth  the  price.  In  fact, 
price  should  not  be  considered  in  purchasing  such 
a  work.  If  the  money  put  into  some  of  our  sci- 
called  standard  text-books  could  be  converted  into 
such  publications  as  this,  much  good  would  result. 
—Southern  Dental  Journal,  May,  1882. 


The  author  brings  to  his  task  a  large  experience 
acquired  under  the  most  favorable  circumstances. 
There  have  been  added  to  the  volume  a  hundred 
pages  by  the  American  editor,  embodying  the 
views  of  the  leading  home  teachers  in  dental  sur- 
gery. The  work,  therefore,  may  be  regarded  as 
strictly  abretist  of  the  times,  and  as  a  very  high 
authority  on  the  subjects  of  which  it  treats. — 
American  Practitioner,  July,  1882. 


BASHAM    ON   RENAL  DISEASES:    A  Clinical 
Guide  to  their  Diagnosis  and  Treatment.    In 


one  12mo.  vol.  of  304  pages,  with  21  illostratlODS. 

Cloth,  82.00. 


Lea  Brothers  &  Co.'s  Publications — Venereal,  Impotence. 


25 


GJROSS,  SAMUEL  W.,  A,  M,,  M,  D.,  LL.  D., 

Professor  of  the  Principlcn  of  Surgery  and  of  Clinical  Surgery  in  the  Jeffernon  Mclicnl  College  of  Philn. 

A  Practical  Treatise  on  Inapotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  New  (third)  edition,  tlioruuglily  revised.  In  one  very 
handsome  octavo  volume  of  163  pages,  with  16  illustrations.     Cloth,  $1.50. 


It  must  be  gratifying  to  both  author  and  pub- 
lishers that  large  first  and  .second  editions  of  this 
little  work  were  so  soon  exhausted,  while  the  fact 
that  it  liiis  befn  translated  into  Russian  may  indi- 
cate that  it  filled  a  void  even  in  foreign  literature. 
His  is  a  careful  and  physiologioal  study  of  the 
Bexual  act,  so  far  as  concerns  the  male,  and  all 
his  conclusions  are  scientifically  reached.  The 
book  has  a  place  by  itself  in  our  literature,  and 
furnishes  a  large  fund  of  information  concerning 
important  matters  that  are  too  often  passed  over 
in  silence. — The  Medical  Press,  June,  1887. 


Thi.H  now  classical  work  on  tlio  subject  of  Impo- 
tence and  sterility  in  the  male  needs  no  eztenaed 
review,  for  it  is  already  well  known  to  the  f/ro- 
fession.  Dr.  Gross  has  by  his  tireless  labor  done 
more  towards  clearing  up  the  diagnosis  and  treat- 
mentof  these  obscure  cases  than  any  other  Ameri- 
can i)hy8ician.  The  fact  that  this  book  has  rapidly 
run  through  two  large  edit  ions,  and  that  the  author 
is  now  forced  to  issue  a  third,  is  good  and  sufficient 
evidence  of  its  excellence. — Atlanta  Medical  and 
Surgical  Journal,  April,  1888. 


TAYLOJR,  a,  W,,  A,  M,,  M.  J>., 

Surgeon  to  Cfiarity  Hospital,  New  York,  Prof,  of  Venereal  and  Skin  Diseases  in  the  University  of 
Vermont,  Pres.  of  the  Am.  Dermatological  Ass'n. 

The  Pathologjr  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  Being  the  sixth  edition  of  Bumstead 
and  Taylor.  Entirely  rewritten  by  Dr.  Taylor.  Large  and  handsome  8vfi.  volume, 
about  900  pages,  with  about  150  engravings,  as  well  as  numerous  chromo-lithographs. 

Preparinr/. 

A  few  notices  of  the  previous  edition  are  appended. 

It  is  a  splendid  record  of  honest  labor,  wide 
research,  just  comparison,  careful  scrutiny  and 
original  experience,  which  will  always  be  held  as 
a  high  credit  to  American  medical  literature.  This 
is  not  only  the  best  work  in  the  English  language 
upon  the  subjects  of  which  it  treats,  but  also  one 
wnich  has  no  equal  in  other  tongues  for  its  clear, 
comprehensive  and  practical  handling  of  its 
themes. — Am.  Jour,  of  the  Med.  Sciences,  Jan,  1884. 

It  is  certainly  the  best  single  treatise  on  vene- 
re'  in  our  own,  and  probably  the  best  in  any  lan- 
guage.— Boston  Med.  and  Sicrg.  Journal,  April  3, 1884. 

The  character  of  this  standard  work  is  80  well 


known  that  it  would  be  superfluous  here  to  pass  In 
review  its  general  or  special  points  of  excellence. 
The  verdict  of  the  profession  has  been  passed;  it 
has  been  accepted  as  the  most  thorough  and  com- 
plete exposition  of  the  pathology  and  treatment  of 
venereal  diseases  in  the  language.  Admirable  as  a 
model  of  clear  description,  an  exponent  of  sound 
pathological  doctrine,  and  a  guide  for  rational  and 
successful  treatment,  it  is  an  ornament  to  the  medi- 
cal literature  of  this  country.  The  additions  made 
to  the  present  edition  are  eminently  judicious 
from  the  standpoint  of  practical  utility. — Joumalof 
Cutaneous  and  Venereal  LHsecises,  Jan.  1884. 


COMNIL,  F., 

Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Loureine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  by  the  Author,  and  translated  with  notes  and  additions  by  J.  Henky  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  University  of  Pennsylvania,  and 
J.  William  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  Surgery 
in  the  University  of  Pennsylvania,  In  one  handsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustrations.     Cloth,  $3.75. 

perusal  without  the  feeling  that  his  grasp  of  the 

wide  and  important  subject  on  which  it  treats  is 

stronger  and  surer   one. — The  London  Practi- 


The  anatomy,  the  histology,  the  pathology  and 
the  clinical  features  of  syphilis  are  represented  in 
this  work  in  their  best,  most  practical  and  most 
inatructive  form,  and  no  one  will  rise  from  its 


tioner,  Jan.  1882. 


MTITCSIWSON,  JOWATSAN,  F,  B.  S,,  F,  JR.  C,  S,, 

Consulting  Surgeon  to  the  London  Hospital. 
Syphilis.     In  one  12mo.  volume  of  542  pages,  with  8  chromo-lithographs. 
$2,25.     See  Series  of  Clinical  Manuals,  page  4. 


Cloth, 


Those  who  have  seen  most  of  the  disease  and 
those  who  have  felt  the  real  difficulties  of  diagno- 
sis and  treatment  will  most  highly  appreciate  the 
facts  and  suggestions  which  abound  in  these 
pages.  It  is  a  worthy  and  valuable  record,  not 
only  of  Mr.  Hutchinson's  very  large  experience 


and  power  of  observation,  hut  of  his  patience  and 
assiduity  in  taking  notes  of  his  cases  and  keep- 
ing them  in  a  form  available  for  such  excellent 
use  as  he  has  put  them  to  in  this  volume. — London 
Medical  Record,  Nov.  12,  1887, 


GROSS,  S,  JD,,  M.  D.,  LL.  D.,  D.  C,  L.,  etc. 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Third 
edition,  thoroughly  revised  by  Samuel  W.  Gkoss,  M.  D.  In  one  octavo  volimie  of  574 
pages,  with  170  illustrations.     Cloth,  $4.50, 

CUZLFJRIFH,  a.,  &  BUMSTFAD,  F.  J.,  3I.D.,  ll.b., 

Surgeon  to  the  H6pital  du  Midi.         Late  Professor  of  Venereal  Diseases  in  the  College  of  Physician* 

and  Surgeons,  JV'eu)  York. 

An  Atlas  of  Venereal  Diseases.  Translated  and  edited  by  Freeman  J.  Bum- 
stead,  M.  D.  In  one  imperial  4to.  volume  of  328  pages,  double-columns,  with  26  plates, 
containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of  life.  Strongly 
bound  in  cloth,  $17.00.    A  specimen  of  the  plates  and  text  sent  by  mail,  on  receipt  of  25  eta. 

HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  I  FORMS    OF     LOCAL     DISEASE    AFFECTING 

DISORDERS.  In  one  8vo  vol.  of  479  p.  Cloth,  83.26.  I  PRINCIPALLY    THE    ORGANS   OF    GENERA- 

LEE'a  LECTURES  ON  SYPHILIS  AND  SOME  1  TION.    In  one  Svo.  vol.  of  246  pages.    Cloth,  82.26. 


26 


Lea  BaoTHEEs  &  Co.'s  Publications — Venereal,  Skiii. 


TATLOB,  ROBERT  W.,  A.M.,  M.D., 

Surgeon  In  Chnrit'i  Uospilnl,  New  York,  and  lo  the  Department  of  Venereal  and  Skin  Ditetuet  of 
the'.\tio  V'jrk  Jl'/^rnlal. 

A  Clinical  Atlas  of  "Venereal  and  Skin  Diseases:  Including  Diagnosis, 
Prognosis  and  Treatment.  In  eight  large  folio  parts,  measuring  14  x  18  inches,  and 
comprising  68  beautifully-colored  plates  with  184  figures,  and  42-5  pages  of  text  with  85 
engravings.  Complete  work  just  ready.  Price  per  part,  $2.50.  Bound  in  one  volume, 
half  Russia,  $27;  half  Turkey  Morocco,  $28.  For  sale  by  subscriplion  only.  Specimen  plates 
sent  on  receipt  of  10  cents.    A  full  prospectus  sent  to  any  address  on  application. 

This  magnificent  CUnicnl  Atlas,  we  donothesi-  j  recognized  su^  a  standard  »ulhority  on  its  subjects, 
tate  to  say,  will  be  regarded  as  one  of  the  most  The  strong  fnith  of  its  publishers  in  the  merit 
valuable  and  handsome  contributions  to  the medi-  and  wide  appreciation  which  they  must  feel 
cal  literature  of  the  age.  As  its  name  implies,  the  |  assured  awaits  the  Clinical  Atlas  at  the  hands  of  a 
Clinical  Atlas  is  intended  as  a  working  guide  for  j  discriminating  medical  public  is  evidenced  by 
any  practitioner  who  chooses  to  deal  with  the  wide-  j  the  very  moderate  figure  at  which  it  is  supplied,  a 
spread  class  of  chronic  diseases  included  in  its  ''  figure  so  much  below  that  customarily  charged 
title.    For  the  adequate   accomplishment  of   its  |  for   works  of  this  class  that  only  the  widest  tlis- 

fiurpose  such  a  work  must  comprise  pictures,  life-  I  semination  can  possibly  bring  them  a  fair  return 
ike  in  form  and  color,  of  a  size  as  large  as  is  com-  i  for  their  evidently  lavish  outlay. — Southern  Prac- 
patible  with  convenience,  together  with  a  descrip-    litioner,S&pt.,  1888. 

tire,  clinical  and  didactic  text.     The  entire  litera-       Viewing  this  collection  as  awhole  it  may  be  said 
ture  of  the  subjects  has  baen  searched  for  its  best  ]  that  it  is  difficult  to  overestimate  its  clinical  value 


illustrations,  and  selections  made  with  proper 
permission  of  living  authors.  These  have  been 
complemented  by  numerous  reproductions  from  a 
collection  of  original  paintings  from  life,  gathered 
by  the  author  during  many  years  of  practice.  The 
text  tias  been  designed  to  furnish  the  practitioner 
with  clear  and  explicit  directions  for  the  proper 
management  of  his  csises,  and  at  the  same  time  to 
stimulate  the  interest  of  those  who  may  wish  to 
devote  their  life-work  to  these  subjects.  A  full 
statement  of  the  clinical  history,  varying  features, 
etiology,  diagnosis,  and  prognosis  has  therefore 
been  followed  by  definite  and  complete  thera- 
peutical information.  In  their  respective  spheres 
the  author  and  publishers  have  left  nothing  undone 
to  make  the  Clinical  Atlas  a  work  which  will  be 


to  the  practitioner  and  diagnostician.  A  careful 
study  of  even  the  smallest  of  these  portraits  of 
disease  will  repay  the  student.  Their  practical 
value  in  teaching  is  exactly  proportioned  to  their 
faithfulness  to  fact.  In  the  important  matters  of 
etiology  and  treatment,  the  author  is  as  lucid  and 
practical  as  might  be  anticipated  from  one  of  his 
experience  and  previous  contributions  to  derma- 
tological  literature.  Dr.  Taylor's  Atlas  is  to  be 
warmly  commended  to  the  expert,  the  general 
practitioner,  and  the  student,  as  an  invaluable  aid 
in  acquiring  a  knowledge  of  the  subjects  illus- 
trated, combining  in  a  high  degree  the  advantages 
of  a  sound  text-book,  with  the  special  assistance 
of  colored  illustrations. — The  ATnerican  Journal  of 
the  Medical  Sciences,  April,  1889. 


MYDJE,  J.  mSVINS,  A.  M.,  M.  D., 

Professor  of  Dermatology  and  Venereal  Diseases  in  Rush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students  and 
Practitioners.  New  (second)  edition.  In  one  handsome  octavo  volume  of  676  pages, 
with  2  colored  plates  and  85  beautiful  and  elaborate  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50.    Just  ready. 


We  can  heartily  commend  it,  not  only  as  an 
admirable  texi^book  for  teacher  and  student,  but 
in  its  clear  and  comprehensive  rules  for  diagnosis, 
its  sound  and  independent  doctrines  in  pathology, 
and  its  minute  and  judicious  directions  for  the 
treatment  of  di.^ease,  as  a  most  satisfactory  and 
complete  practical  guide  for  the  physician.— .4 7«ert- 
can  Journal  of  the  Medical  Sciences,  July,  1888. 

A  useful  glossary  descriptive  of  terms  is  given. 
The  descriptive  portions  of  this  work  are  plain 
and  easily  understood,  and  above  all  are  very 
accurate.  The  therapeutical  part  is  abundantly 
supplied  with  excellent  recommendations.  The 
picture  part  is  well  done.  Tlie  value  of  the  work 
to  practitioners  is  great  because  of  the  excellence 
of  the  descriptions,  the  suggestiveness  of  the 
advice,  and  the  correctness  of  the  details  and  the 
principles  of  therapeutics  impressed  upon  the 
Te&der.—  Viy  ginia  Med.  Monthly,  May,  1888. 


The  second  edition  of  his  treatise  is  like  his 
clinical  instruction,  admirably  arranged,  attractive 
in  diction,  and,  strikingly  practical  throughout. 
The  chapter  on  general  symptomatology  is  a  model 
in  its  way ;  no  clearer  description  of  the  various 

Erimary  and  consecutive  lesions  of  the  .skin  is  to 
e  met  with  anywhere.  Those  on  general  diagno- 
sis and  therapeutics  are  also  worthy  of  careful 
study.  Dr.  Hyde  has  shown  himself  a  compre- 
hensive re(»der  of  the  latest  literature,  and  has  in- 
corporated into  his  book  all  the  best  of  that  which 
the  past  years  have  brought  forth.  The  prescrip- 
tions and  formulae  are  given  in  both  common  and 
metric  systems.  Text  and  illustrations  are  good, 
and  colored  plates  of  rare  cases  lend  additional 
attractions.  Altogether  it  is  a  work  exactly  fitted 
to  the  needs  of  a  general  practitioner,  and  no  one 
will  make  a  mistake  in  purchasing  it. — Medical 
Press  of  Western  JS'ew  York,  June,  1888. 


FOX,  T.,  M.  D.,  F.B.  C.  JP.,  and  FOX,  T.  C,  B.A.,  M.B.  C.S., 

Physician  to  the  Departvient  for  Skin  Diseases,  Physician  for  Diseases  of  the  Skin  to  the 

University  College  Hospital,  London.  Westminster  Hospital,  London. 

An  Epitome  of  Skin  Diseases.  With  Formulae.  For  Students  and  Prac- 
titioners. Third  edition,  revised  and  enlarged.  In  one  very  handsome  12mo.  volume 
of  238  pages.     Cloth,  $1 .25. 

The  third  edition  of  this  convenient  handbook  I  manual  to  He  upon  the  table  for  instant  reference, 
calls  for  notice  owing  to  the  revision  and  expansion  1  Its  alphabetical  arrangement  is  suited  to  this  use, 


which  it  has  undergone.  The  arrangement  of  skin 
disea-ses  in  alphaVietical  order,  which  is  the  method 
of  classification  adopted  in  this  work,  becomes  a 
positive  advantage  to  the  student.  The  book  is 
one  which  we  can  strongly  recommend,  not  only 


for  all  one  htus  to  know  is  the  name  of  the  disease, 
and  here  are  its  description  and  the  appropriate 
treatment  at  hand  and  ready  for  instant  applica- 
tion. The  present  edition  has  been  very  carefully 
revised  and  a  number  of  new  diseases    are  de- 


to  students  but  also  to  practitioners  who  require  a  I  scribed,  while  most  of  the  recent  additions  to 
compendious  summary  of  the  present  state  of  dermal  therapeutics  find  mention,  and  the  formu- 
dermatologv.— £ri7(.sA  'Medical  Journal,  July  2, 1883.  '  lary  at  the  end  of  the  book  has  been  considerably 

We  cordially  recommend  Fox's  Epitome  to  those  |  augmented.— T/ie  J/edicaJ  News,  December,  1883. 
whose  time  is  limited  and  who  wish    a   handy  | 


WILSON,  EBAS3IUS,  F.B.S. 

The  Student's  Book  of  Cutaneous  Medicine  andDiseases  of  the  Skitu 
Tn  one  handsome  small  octavo  volume  of  535  pages.     Cloth,  $3.50. 


HILLTER'S  HANDBOOK  OF  .SKIX  DISEASES; 
for  Students  and  Practitioners.    Second  Ameri- 


can edition, 
with  plates. 


In  one  12mo.  volume  of  353  pages. 
Cloth,  S2.2o. 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women. 


27 


The  American  Systems  of  Gynecology  and  Obstetrics. 

Systems  of  Gynecology  and  Obstetrics,  in  Treatises  by  American 
Authors.  Gynecology  edited  by  Matthew  D.  Mann,  A.  M.,  M.  D.,  Professor  of  Obstetrics 
and  Gynecology  in  the  Medical  Department  of  the  University  of  Buffalo;  and  Obstet- 
rics edited  by  Barton  Cooke  Hirst,  M.  D.,  Associate  Professor  of  Obstetrics  in  the 
University  of  Pennsylvania,  Philadelphia.  In  four  very  handsome  octavo  volumes,  con- 
taining 3612  pages,  1092  engravings  and  8  plates.  Complete  work  juat  ready.  Per  vol- 
ume: Cloth,  lo.OO;  leather,  $6.00;  half  Russia,  $7.00.  For  sale  by  subscription  only. 
Address  the  Publishers.     Full  descriptive  circular  free  on  application. 


LIST  OF 

WILLIAM  H.  BAKER,  M.  D., 
ROBERT  BATTEY,  M.  D., 
SAMUEL  C.  BUSEY,  M.  D., 
JAMES  C.  CAMERON,  M.  D., 
HENRY  C.  COE,  A.  M.,  M.  D., 
EDWARD  P.  DAVIS,  M.  D., 
G.  E.  De  SCHWEINITZ,  M.  D., 
E.  C.  DUDLEY,  A.  B.,  M.  D., 
B.  McE.  EMMET,  M.  D., 
GEORGE  J.  ENGELMANN,  M.  D., 
HENRY  J.  GARRIGUES,  A.  M.,  M.  D. 
WILLIAM  GOODELL,  A.  M.,  M.  D., 
EGBERT  H.  GRANDIN,  A.  M.,  M.  D. 
SAMUEL  W.  GROSS,  M.  D., 
ROBERT  P.  HARRIS,  M.  D., 
GEORGE  T.  HARRISON,  M.  D., 
BARTON  C.  HIRST,  M.  D. 
STEPHEN  Y.  HOWELL,  BI.  D., 
A.  REEVES  JACKSON,  A.  M.,  M.  D., 
W.  W.  JAGGARD,  M.  D., 
EDWARD  W.  JENKS,  M.  D.,  LL.  D., 
HOWARD  A.  KELLY,  M.  D., 


CONTRIBUTORS. 

CHARLES  CARROLL  LEE,  M.  D., 
WILLIAM  T.  LUSK,  M.  D.,  LL.  D., 
J.  HENDRIE  LLOYD,  M.  D  , 
MATTHEW  D.  MANN,  A.  M.,  M.  D., 
H.  NEWELL  MARTIN,  F.  R.  S.,  M.  D., 

D.Sc,  M.A., 
RICHARD  B.  MAURY,  M.  D., 
C.  D.  PALMER,  M.  D., 
ROSWELL  PARK,  M,  D., 
THEOPHILUS  PARVIN,  M.  D.,  LL.  D., 
,  R.  A.  F.  PENROSE,  M.  D.,  LL.  D., 

THADDEUS  A.  REAMY,  A.  M.,  M.  D., 

J.  C.  REEVE,  M.  D., 

A.  D.  ROCKWELL,  A.  M.,  M.  D., 

ALEXANDER  J.  C.  SKENE,  M.  D., 

J.  LEWIS  SMITH,  M.  D., 

STEPHEN  SMITH,  M.  D., 

R.  STANSBURY   SUTTON,  A.  M.,  M.  D., 

LL.  D., 
T.  GAILLARD  THOMAS,  M.  D.,  LL.  D., 
ELY  VAN  DE  WARKER,  M.  D., 
W.  GILL  WYLIE,  M.  D. 


This  is  a  very  valuable  contribution  to  the  liter- 
ature of  obstetrics.  The  editors,  contributors  and 
f)ublishers  are  entitled  to  most  hearty  congratu- 
ations  for  the  complete  kind  of  work  that  has 
appeared. — The  Obstetric  Gazette,  August,  1888. 

This,  the  companion  work  to  the  System  of 
Gynecology  by  American  Authors,  equals  it  in  the 
excellence  of  the  subject-matter  and  the  perfec- 
tion of  the  publishers'  art.  As  a  treatise  for  the 
use  of  the  practitioner  the  work  will  be  found  to 
represent  admirably  the  obstetric  science  of  the 
day  as  exemplified  in  American  practice.— TTje 
Medical  Neios,  August  25,  1888. 

There  can  be  but  little  doubt  that  this  work  will 
find  the  same  favor  with  the  profession  that  has 
been  accorded  to  the  "  System  pf  Medicine  by 
American  Authors,"  and  the  "System  of  Gynecol- 
ogy byAmerican  Authors."  One  is  at  a  loss  to  know 
what  to  say  of  this  volume,  for  fear  that  just  and 
merited  praise  maybe  mistaken  for  flattery.  The 
subjects  of  some  of  the  papers  are  discussed  in 
various  works  on  obstetrics,  though  not  to  the  full 
extent  that  is  found  in  this  volume.  The  papers 
of  Drs.  Engelmann,  Martin,  Hirst,  Jaggard  and 
Reeve  are  incomparably  beyond  anything  that  can 
be  found  in  obstetrical  works.  Certainly  the  Edi- 
tor may  be  congratulated  for  having  made  such  a 
wise  selection  of  his  contributors. — Journal  of  the 
American  Medical  Association,  Stpt.  8, 1888. 


In  our  notice  of  the  "System  of  Practical  Medi- 
cine by  American  Authors,"  we  made  the  follow- 
ing statement: — "It  is  a  work  of  which  the  pro- 
fession in  this  country  can  feel  proud.  Written 
exclusively  by  American  physicians  who  are  ac- 
quainted with  all  the  varieties  of  climate  in  the 
United  States,  the  character  of  the  soil,  the  man- 
ners and  customs  of  the  people,  etc.,  it  is  pecul- 
iarly adapted  to  the  wants  of  American  practition- 
ers of  medicine,  and  it  seems  to  us  that  every  one 
of  them  would  desire  to  have  it."  Every  word 
thus  expressed  in  regard  to  the  "American  Sys- 
tem of  Practical  Medicine"  is  applicable  to  the 
"System  of  Gynecology  by  .American  .Authors," 
which  we  desire  now  to  bring  to  the  attention  of 
our  readers.  It,  like  the  other,  has  been  written 
exclusively  by  American  physicians  who  are 
acquainted  with  all  the  characteristics  of  American 
people,  who  are  well  informed  in  regard  to  the 
peculiarities  of  American  women,  their  manners, 
customs,  modes  of  living,  etc.  As  every  practis- 
ing physician  is  called  upon  to  treat  diseases  of 
females,  and  as  they  constitute  a  class  to  which 
the  familly  physician  must  give  attention,  and 
cannot  pass  over  to  a  specialist,  we  do  not  know  of 
a  work  in  any  department  of  medicine  that  we 
should  so  strongly  recommend  medical  men  gen- 
erally purchasing. — Cincinnati  Med.  News,  July,1887» 


TMOMAS,  T,  GAILLAMD,  M,  D., 

Professor  of  Diseases  of  Women  in  the  College  of  Physicians  and  Surgeons,  N.  7. 

A  Practical  Treatise  on  the  Diseases  of  Women.  Fifth  edition,  thoroughly 
revised  and  rewritten.  In  one  large  and  handsome  octavo  volume  of  810  pages,  with  266 
illustrations.     Cloth,  $5.00 ;  leather,  $6.00. 

That  the  previous  editions  of  the  treatise  of  Dr.  rician  and  gyncecologist  as  a  safe  guide  to  practice. 
Thomas  were  thought  worthy  of  translation  into  No  small  number  of  additions  have  been  made  to 
German,  French,  Italian  and  Spanish,  is  enough  the  present  edition  to  make  it  correspond  to  re- 
to  give  it  the  stamp  of  genuine  merit.  At  home  it  cent  improvements  in  treatment. — Pacific  Medical 
das  made  its  way  into  the  library  of  every  obstet-    and  Surgical  Journal,  Jstn.  1881. 


UDIS,  AUTJETUIt  W„  M,  D.,  Lond,,  F.B.  C.  JP.,  M.B.  C.S., 

Assist.  Obstetric  Physician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  Hospital. 
The  Diseases  of  Women.     Including  their  Pathology,  Causation,  Symptoms, 
Diagnosis  and  Treatment.     A  Manual  for  Students  and  Practitionei-s.     In  one  handsome 
octavo  volume  of  576  pages,  with  14b  illustrations.     Cloth,  $8.00 ;  leather,  $4.00. 

It  is  a  pleasure  to  read  a  boon  so  thoroughly  1  are  among  the  more  common  methods  of  treat- 
good  as  this  one.  The  special  qualities  which  are  ment,  ana  yet  very  little  is  said  about  them  in 
conspicuous  are  thoroughness  in  covering  the  many  of  the  text-books.  The  book  is  one  to  be 
whole  ground,  clearness  of  description  and  con-    warmly  recommended  especially  to  students  and 


ciseness  ot  statement.  Another  marked  feature  of 
the  book  is  the  attention  paid  to  the  details  of 
many  minor  surgical  operations  and  procedures, 
as,  for  instance,  the  use  of  tents,  application  of 
leeches,  and  use  of  hot  water  injections.    These 


general  practitioners,  who  need  a  concise  but  com- 
plete regime  of  the  whole  subject.  Specialists,  too, 
will  find  many  useful  hints  in  its  pages. — Boston 
Med.  and  Surg.  Joum.,  March  2, 1882. 


28         Lea  Brothers  &  Oo.'s  Publications — Dis.  of  Women,  Midwfy. 
BMMET,  THOMAS  ADBIS,  M,  D,,  LL,  J>., 

Surgeon  to  the  Woman's  Hospital,  Neio  York,  etc. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students  and 
Practitioners  of  Medicine.  Kew  (tiiird)  edition,  thoroughly  revised.  In  one  large  and  very 
handsome  octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  $5;  leather,  $6; 
very  handsome  half  Bussia,  raised  bands,  $6.50. 

snce  of  the  third  edition  of  this  well-known  work. 


The  time  has  passed  when  Emmet's  Oyncccology 
was  to  be  regarded  as  a  book  for  a  single  country 
or  for  a  single  generation.  It  has  always  been  his 
aim  to  popularize  gynaecology,  to  bring  it  within 
easy  reach  of  the  general  practitioner.  The  orig- 
inality of  the  ideas  compels  our  admiration  and 
respect.  We  may  well  take  an  honest  pride  in 
Dr.  Emmet's  work  and  feel  that  his  book  can 
hold  its  own  against  the  criticism  of  two  conti- 
nents. It  represents  all  that  is  most  earnest  and 
most  thoughtful  in  American  gyniecology. — Amer- 
ican Journal  of  Obstetrics,  May,  1885. 

We  are  in  doubt  whether  to  congratulate  the 
author  more  than  the  profession  upon  the  appear- 


Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  conspicuously  distinguished  hiipself 
as  a  hold  and  successful  operator,  and  wh<»  has 
devoted  so  much  attention  to  the  specialty,  we 
feel  sure  the  profession  will  not  fail  to  appreciate 
the  privilege  thus  offered  them  of  perusing  the 
views  and  practice  of  the  author.  His  earnestness 
of  purpose  and  conscientiousness  are  manifest. 
He  gives  not  only  his  individual  experience  but 
endeavors  to  represent  the  actual  state  of  gynee- 
cological  science  and  art. — British  Medical  Jour- 
nal, May  16, 1885. 


TAIT,  LA  WSOJSr,  F.  B,  C,  S.^ 

Fellow  of  the  Royal  Medico- Cliirurgical  Society^  London,  Honorary  Member  of  the  Boston  Oyne- 
cological Society,  Surgeon  to  the  Birmingham  ana>Midland  Hospital  for  Women. 

Diseases  of  Women  and  Abdominal  Surgery.  In  one  very  handsome 
octavo  volume  of  600  pages,  fully  illustrated.     In  press. 

DAVEJS^POItT,  F,  H.,  M,  !>., 

Assistant  in  Gyncecology  in  the  Medical  Department  of  Harvard  University,  Boston. 

Diseases  of  Women,  a  Manual  of  Non-Surgical  Gynsecology.  De- 
signed especially  for  the  Use  of  Students  and  General  Practitioners.  In  one  handsome 
12mo.  volume  of  317  pages,  with  105  illustrations.     Cloth,  $1.50.     Just  ready. 

FROM  THE  PREFACE. 

This  book  has  two  main  objects:  in  the  first  place  to  give  the  student  clearly  but 
with  considerable  detail  the  elementary  principles  of  the  methods  of  examination  and  the 
simple  forms  of  treatment  of  the  most  common  diseases  of  the  pelvic  organs ;  and  in  the 
second  place  to  help  the  busy  general  practitioner  to  understand  and  treat  the  gynaecolog- 
ical cases  which  he  meets  with  in  the  course  of  his  everyday  practice.  The  treatment 
has  been  mainly  confined  to  such  measures  as  have  been  practically  found  of  the  greatest 
benefit  in  the  author's  hands. 

J)VNCA:N^,  J,  MATTHEWS,  M,D,,  LL,  D.,  F,  H.  S,  F.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered  in  Saint  Bar- 
tholomew's Hospital.     In  one  handsome  octavo  volume  of  175  pages.    Cloth,  $1.50. 

rule,  adequately  handled  in  the  text-books ;  others 
of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  length  in  such  works,  yet  bear  such  a 


They  are  in  every  way  worthy  of  their  author ; 
indeed,  we  look  upon  them  as  among  the  most 
valuable  of  his  contributions.  They  are  all  upon 
matters  of  great  interest  to  the  general  practitioner. 
Some  of  them  deal  with  subjects  that  are  not,  as  a 


stamp  of  Individuality  that  they  deserve  to  be 
widely  read. — N.  Y.  Medical  Journal,  March,  1880. 


MAT,   CHABLFS  H,,  M,  H., 

Late  House  Surgeon  to  Mount  Sinai  Hospital,  New  York. 

A  Manual  of  the  Diseases  of  Women.  Being  a  concise  and  systematic  expo- 
sition of  the  theory  and  practice  of  gynaecology.  In  one  12mo,  volume  of  342  pages; 
Cloth,  $1.75. 

HOHGF,  JaUGHL.,  31,  2)., 

Emeritus  Professor  of  Obstetrics,  etc.,  in  the  University  of  Pennsylvania. 
On  Diseases  Peculiar  to  Women;  Including  Displacements  of  the  Uterus. 
Second  edition,  revised  and  enlarged.    In  one  beautifully  printed  octavo  volume  of  619 
pages,  with  original  illustrations.    Cloth,  $4.50. 

By  the  Same  Author. 
The  Principles  and  Practice  of  Obstetrics.  Illustrated  with  large  litho- 
graphic plates  containing  159  figures  from  original  photographs,  and  with  nimierous  wood- 
cuts. In  one  large  quarto  volume  of  542  double-columned  pages.  Strongly  bound  in 
cloth,  $14.00.  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address, 
free  by  mail,  on  receipt  of  six  cents  in  postage  stamps. 

MAMSBOTHAM,  FBANCIS  FT.,  31.  H, 

The  Principles  and  Practice  of  Obstetric  Medicine  and  Surgery: 

In  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly  revised 
by  the  Author.  With  additions  by  "VV.  V.  Keating,  M.  D.,  Professor  of  Obstetrics,  etc., 
in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full-page  plates  and  43  woodcuts  in  the  text,  contain- 
ing in  all  nearly  200  beautiful  figures.     Strongly  bound  in  leather,  with  raised  bands,  $7. 

WFST,  CHABLFS,  31.  J). 

Lectures  on  the  Diseases  of  Women.  Third  American  from  the  third  Lon- 
don edition.    In  one  octavo  volume  of  543  pages.    Cloth,  $3.75 ;  leather,  $4.75. 


Lea  Brothers  &  Co.'s  Publications — Midwifery. 


29 


PABVUS^,  THEOPHILVS,  M,  D.,  LL.  D., 

Prof,  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  Jefferson  Med.  Coll.,  Phila. 

The  Science  and  Art  of  Obstetrics.    In  one  handsome  8vo,  volume  of  697 
pages,  with  214  engravings  and  a  colored  plate.    Cloth,  $4.25 ;  leather,  $5.25. 

It  is  a  ripe  harvest  that  Dr.  Parvin  offers  to  his 
readers.    There  Is  no  book  that  can  be  more  fafel  v 


recommended  to  the  student  or  that  can  be  turned 
to  in  moments  of  doubt  with  greater  assurance  of 
aid,  as  it  is  a  liberal  digest  of  sBife  counsel  that  has 
been  patiently  gathered. —  The  American  Journal 
of  the  Medical  Sciences,  July,  1887. 

Tliere  is  not  in  the  language  a  treatise  on  the 
subject  which  so  completely  and  intelligently 
gleans  the  whole  field  of  obstetric  literature,  giv- 
ing the  reader  the  winnowed  wheat  in  concise  and 


well-jointed  phrase,  in  language  of  exceptional 
purity  and  strength.  The  arrangement  of  the 
matter  of  this  work  is  unique  and  exceedingly 
favorable  for  an  agreeable  unfolding  of  the  science 
and  art  of  obstetrics.  This  new  book  is  the  easy 
superior  of  any  single  work  among  its  predeces- 
sors for  the  student  or  practitioner  seeking  the 
best  thought  of  the  day  in  this  department  of 
medicine. — The  American  Practitioner  and  News, 
April  2, 1887. 


BAMNES,  BOBJEBT,  M,  J).,   mid   FAJSTCOVBT,  M.  !>., 

Phys.  to  the  General  Lying-in  Eosp.,  Lond.  Obstetric  Phys.  to  St.  Thomas^  Hosp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  contributed  by 
Prof.  Milnes  Marshall.  In  one  handsome  octavo  volume  of  872  pages,  with  231  illus- 
trations.   Cloth,  $5 ;  leather,  $6. 


The  immediate  purpose  of  the  work  is  to  furnish 
a  handbook  of  obstetric  medicine  and  surgery 
for  the  use  of  the  student  and  practitioner.  It  is 
not  an  exaggeration  to  say  of  the  bonk  that  it  is 
the  best  treatise  in  the  English  language  yet 
published,  and  this  will  not  be  a  surprise  to  those 
who  are  acquainted  with  the  work  of  the  elder 
Barnes.     Every  practitioner  who  desires  to  have 


the  best  obstetrical  opinions  of  the  time  in  a 
readily  accessible  and  condensed  form,  ought  to 
own  a  copy  of  the  book. — Journal  of  the  American 
Medical  Association,  June  12,  1886. 

The  Authors  have  made  a  text-book  which  is  in 
every  way  quite  worthy  to  take  a  place  beside  the 
best  treatises  of  the  period. — New  York  Medical 
Journal,  July  2, 1887. 


rZAYFAIB,  W,  S,,  M,  D,,  F,  B,  C,  J>., 

professor  of  Obstetric  Medicine  in  King^s  College,  London,  etc, 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  New  (fifth) 
American,  from  the  seventh  English  edition.  Edited,  with  additions,  by  Egbert  P.  Has- 
Eis,  M.  P.     In  one  handsome  octavo  volume  of  about  700  pages,  with  3  plates  and  about 

200  engravings.     In  press. 

A  notice  of  the  previous  edition  is  appended. 


Students  and  practitioners  alike  have  already 
found  out  the  advantage  of  possessing  a  work  em- 
bodying all  the  recent  advances  in  the  science 
and  practice  of  midwifery.  It  has  deservedly  he- 
come  a  standard  treatise  upon  the  subject.  The 
Author  has  endeavored  to  dwell  especially  on  the 
practical  part  of  the  subject,  so  as  to  make  the 
work  a  useful  guide  in  this  most  anxious  and  re- 


sponsible branch  of  the  profession.  At  the  same 
time,  the  purely  theoreti^cal  portion  has  not  been 
neglected.  Dr.  Playfair's  treatise  may  fairly  be 
said  to  represent  the  modern  school  of  teaching. 
It  is  a  well-arranged  and  carefully  digested 
epitome  of  the  science  and  practice  of  midwifery 
which  has  greatly  contributed  to  the  advancement 
of  the  study.— British  Medical  Journal,  Jan.  3, 1885. 


KING,  A,  F,  A.,  M,  D,, 

Professor  of  Obstetrics  and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 

A  Manual  of  Obstetrics.     IS^ew  (fourth)  edition.     In  one  very  handsome  12mo. 
volume  of  about  400  pages,  with  140  illustrations.     In  press. 
A  notice  of  the  previous  edition  is  appended. 


This  little  manual,  certainly  the  best  of  its  kind, 
fully  deserves  the  popularity  which  has  made  a 
third  edition  necessary.  Clear,  practical,  concise, 
its  teachings  are  so  fully  abreast  with  recent  ad- 


vances in  obstetric  science  that  but  few  points 
can  be  criticised. — American  Journal  of  Obstetrics, 
March,  1887. 


BABKFB,  FOBDTCF,  A.  M.,  M,  J).,  LL,  B.  Fdin,, 

Clinical  Professor  of  Midwifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical  College, 
NeiB  York,  honorary  Fellow  of  the  Obstetrical  Societies  of  London  and  Edinburgh,  etc.,  etc. 

Obstetrical  and  Clinical  Essays.    In  one  handsome  12mo.  volume  of  about 
300  pages.     Preparing. 

BABBT,  JOBJS'  S.,  M.  B., 

Obstetrician  to  the  Philadelphia  Hospitcd,  Vice-President  of  the  Obstet.  Society  of  Philadelphia. 
Extra  -  Uterine  Pregnancy :  Its  Clinical  History,   Diagnosis,  Prognoeds  and 
Treatment.     In  one  handsome  octavo  volume  of  272  pages.     Cloth,  $2.50. 


WrS^CKFL,  F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  and  Practitioners.     Translated,  with  the  consent  of  the  Author,  from  the 
second  German  edition,  by  J.  R.  Chadwick,  M.  D.    Octavo  484  pages.    Cloth,  $4.00, 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE 
DISEASES  PECULIAR  TO  WOMEN.  Third 
American  from  the  third  and  revised  London 
edition.    In  one  8vo.  vol.,  pp.  520.    Cloth,  $3.50. 

TANNER  ON  PREGNANCY.  Octavo,  490  pages, 
colored  plates,  16  cuts.    Cloth,  §4,25. 


CFTTRCHILL  ON  THE  PUERPERAL  FEVER 
AND  OTHER  DISEASES  PECULIAR  TO  WO- 
MEN.   In  one  8vo.  vol.  of  464  pages.    Cloth,  82.50. 

MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  In  one  8vo, 
volume  of  346  pages.    Cloth,  82.00. 


-V 


30 


Lea  Brothers  &  Co.'s  Publications — Midwiy.,  Dis.  Childn. 


LEISHWA  W,  WILLIA3I,  M,  D., 

Regius  Professor  of  Midwifery  in  the  University  of  Qlasgow,  etc, 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
P^ierperal  State.  Third  American  edition,  revised  by  the  Author,  with  additions  by 
John  S.  Parry,  M.  D.,  Obstetrician  to  the  Philadeljdiia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  pages,  with  205  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50. 


The  author  Is  broad  in  his  teachings,  and  dis- 
cusses briefly  the  comparative  anatomy  of  the  pel- 
vis and  the  mobility  of  the  pelvic  articulations. 
The  second  chapter  is  devoted  especially  to 
the  study  of  the  pelvis,  while  in  the  third  the 
female  organs  of  generation  are  introduced. 
The  structure  and  development  of  the  ovum  are 
admirably  described.  Then  follow  chapters  upon 
the  various  subjects  embraced  in  the  study  of  mid- 
wifery. The  descriptions  throughout  the  work  are 
plain  and  pleasing.  It  is  sufficient  to  state  that  in 
this,  the  last  edition  of  this  well-known  work, every 
recent  advancement  in  this  field  has  been  brought 
forward. — Physician  and  Stirgeoyi,  Jan.  1880. 

To  the  American   student  the  work  before  us 


must  prove  admirably  adapted.  Complete  in  all  its 
parts,  essentially  modern  in  its  teachings,  and  with 
demonstrations  noted  for  clearness  and  precision, 
it  will  gain  in  favor  and  be  recognized  a,s  a  work 
of  standard  merit.  The  work  cannot  fail  to  be 
popular  and  is  cordially  recommended. — N.  O. 
Med.  and  Surg.  Journ.,  March,  1880. 

It  has  been  well  and  carefully  written.  The 
views  of  the  author  are  broad  and  liberal,  and  in- 
dicate a  well-balanced  judgment  and  matured 
mind.  We  observe  no  spirit  of  dogmatism,  but 
the  earnest  teaching  of  the  thoughtful  observer 
and  lover  of  true  science.  Take  the  volume  as  a 
whole,  and  it  has  few  equals. — Maryland  Medical 
Journal,  Feb.  1880. 


ZAJ^DIS,  HENHY  G,,  A,  M,,  M,  JD,, 

Professor  of  Obstetrics  and  the  Diseases  of  Women  in  Starling  Medical  College,  Columbus,  O. 

The  Management  of  Labor,  and  of  the   Lying-in  Period.     In 

handsome  12mo.  volume  of  334  pages,  with  28  illustrations.     Cloth,  $1.75. 


one 


The  author  has  designed  to  place  in  the  hand; 
of  the  young  practitioner  a  book  in  which  he  can 
find  necessary  information  in  an  ijistant.  As  far 
as  we  can  see",  nothing  is  omitted.  The  advice  is 
sound,  and  the  proceedures  are  safe  and  practical. 
Centralblatt  fiir  Gynakologie,  December  4,  1886. 

This  is  a  book  we  can  heartily  recommend. 
the  author  goes  much  more  practically  into  the 
details  of  the  management  of  labor  than  most 
text-books,  and  is  so  readable  throughout  as  to 


tempt  any  one  who  should  happen  to  commence 
the  book  to  read  it  through.  The  author  pre- 
supposes a  theoretical  knowledge  of  obstetrics, 
and  has  consistently  excluded  from  this  little 
work  everything  that  is  not  of  practical  use  in  the 
lying-in  room.  We  think  that  if  it  is  as  widely 
read  as  it  deserves,  it  will  do  much  to  improve 
obstetric  practice  in  general. — New  (Orleans  Medi- 
cal and  Surgical  Journal,  Mar,  1886. 


SMITM,  J,  LBWISf  M.  D,, 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College,  N.  Y. 

A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  New  (sixth) 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  867 
pages,  with  40  illustrations.    Cloth,  $4.50 ;  leather,  $5.50. 

For  years  it  has  stood  high  in  the  confidence  of 
the  profession,  and  with  the  additions  and  alter 


ations  now  made  it  may  be  said  to  be  the  best 
book  in  the  language  on  the  subject  of  which  it 
treats.  An  examination  of  the  text  fully  sus- 
tains the  claims  made  in  the  preface,  that  "in 
preparing  the  sixth  edition  the  author  has  revised 
the  text  to  such  an  extent  that  a  considerable 
part  of  the  book  may  be  considered  new."  If  the 
young  practitioner  proposes  to  place  in  his  library 
but  one  book  on  the  diseases  of  children,  we 
would  unhesitatingly  say,  let  that  book  be  the  one 
which  is  the  subject  of  this  notice. — The  American 
Journal  of  the  Medical  Sciences,  April,  1886. 

No  better  work  on  children's  diseases  could  be 
placed  in  the  hands  of  the  student,  containing,  as 
It  does,  a  very  complete  account  of  the  symptoms 
and  pathology  of  the  diseases  of  early  life,  and 
possessing  the  further  advantage,  in  which  it 
stands  alone  amongst  other  works  on  its  subject, 
of  recommending  treatment  in  accordance  with 
the  most  recent  therapeutical  views. — British  and 
Foreign.  Mcdico-Chirurgxcal  Review. 

Those  familiar  with  former  editions  of  the  work 


will  readily  recognize  the  painstaking  with  which 
this  revision  has  been  made.  Many  of  the  articles 
have  been  entirely  rewritten.  The  whole  work  is 
enriched  with  a  research  and  reasoning  which 
plainly  show  that  the  author  has  spared  neither 
time  nor  labor  in  bringing  it  to  its  present  ap- 
proach towards  perfection.  The  extended  table  of 
contents  and  the  well-prepared  index  will  enable 
the  busy  practitioner  to  reach  readily  and  quickly 
for  reference  the  various  subjects  treated  of  in  the 
body  of  the  work,  and  even  those  who  are  familiar 
with  former  editions  will  find  the  improvements 
in  the  present  richly  worth  the  cost  of  the  work. — 
Atlanta  Medical  and  Surgical  Journal,  Dec.  1S86. 

Dr.  Smith's  work  hasjustly  become  the  standard 
all  over  the  world  as  the  book  on  children's  dis- 
eases. The  whole  book  is  admirable,  both  for  the 
practitioner  and  the  student.  Dr.  Smith  writes 
from  a  large  experience  and  a  close  observation 
of  cases  at  the  bedside.  He  is  extremely  prac- 
tical, and  these  facts  make  the  work  what  it  is — 
the  best  of  all  works  on  the  diseases  of  children. 
—  Virginia  Medical  Monthly,  June,  1886. 


OWEN,  EDMUND,  31.  B,,  F,  JS.  C.  S,, 

Surgeon  to  the  Children's  Hospital,  Great  Ormond  St.,  Loiulon. 

Surgical  Diseases  of  Children.  In  one  12mo.  volume  of  525  pages,  with  4 
chromo-lithographic  plates  and  85  woodcuts.  Cloth,  $2.  See  Series  of  Clinical  Manvxds, 
page  4. 

One  is  immediately  struck  on  reading  this  book 
with  its  agreeable  style  and  the  evidence  it  every- 
where presents  of  the  practical  familiarity  of  its 
author   with    his    subject.      The    book    rnay    be 


honestly  recommended  to  both  students  and 
practitioners.  It  is  full  of  sound  information, 
pleasantly  given. — Annals  of  Surgery,  May,  1886. 


WEST,  CHABLES,  31.  D., 

Physician  to  the  Hospital  for  Sick  Children,  London,  etc.. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood. 

12mo.  volume  of  127  pages.     Cloth,  $1.00. 


In  one  small 


CONDIE'S    PRACTICAL   TREATISE    ON    THE 
DISEASES  OF  CHILDREN.    Sixth  edition,  re- 


vised and  augmented.    In  one  octavo  volume  of 
779  pages.    Cloth,  $5.25 ;  leather,  86.25. 


Lea  Brothers  &  Co.'s  Publications — Med.  Juris.,  Miscel.  31 


TIDY,  CHABLES  METMOTT,  M.  B.,  F.  C.  S., 

Professor  of  Chemistry  arul  of  Forensic  Medicine  aiui  Public  Health  at  the  London  Hospital,  etc 
Legal  Medicine.     Voltime  II.     legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Eape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.     Making  a  very  handsome  imperial  oc- 
tavo volume  of  529  pages.     Cloth,  $6.00 ;  leather,  $7.00. 

Volume  I.     Containing   664    imperial  octavo   pages,  with  two  beautiful  colored 
plates.     Cloth,  $6.00;  leather,  $7.00. 


The  satisfaction  expressed  with  the  first  portion 
of  this  work  is  in  no  wise  lessened  by  a  perusal  of 
the  second  volume.  We  find  it  characterized  by 
the  same  fulness  of  detail  and  clearness  of  ex- 
pression which  we  had  occasion  so  highly  to  com- 
mend in  our  former  notice,  and  which  render  it  so 
valuable    to    the   medical    jurist.      The    copious 


tables  of  cases  appended  to  each  division  of  the 
subject  must  have  cost  the  author  a  prodigious 
amount  of  labor  and  research,  but  they  constitute 
one  of  the  most  valuable  features  of  the  book, 
especially  for  reference  in  medico-legal  trials. — 
Afiierican  Journal  of  the  Medical  Sciences,  April,  1884. 


TAYLOR,  AZEBED  S.,  M.  D., 

Lecturer  on  Medical  Jurisprtidence  and  Chemistry  in  Ouy^s  Hospital,  London. 

A  Manual  of  Medical  Jurisprudence.  Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.  Edited  by  .John  J.  Eeese,  M.  D.,  Professor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.    Cloth,  $5.00 ;  leather,  $6.00. 


The  American  editions  of  this  standard  manual 
have  for  a  long  time  laid  claim  to  the  attention  of 
the  profession  in  this  country;  and  the  eighth 
comes  before  us  as  embodying  the  latest  thoughts 
and  emendations  of  Dr.  Taylor  upon  the  subject 
to  which  he  devoted  his  life  with  an  assiduity  and 
success  which  made  him  jacile  princeps  among 
English  writers  on  medical  jurisprudence.  Both 
the  author  and  the  book  have  made  a  mark  too 
deep  to  be  affected  by  criticism,  whether  it  be 
censure  or  praise.  In  this  case,  however,  we  should 


only  have  to  seek  for  laudatory  terms. — American 
Journal  of  the  Medical  Sciences,  Jan.  1881. 

This  celebrated  work  has  been  the  standard  au- 
thority in  its  department  for  thirty-seven  years, 
both  in  England  and  America,  in  both  the  profes- 
sions which  it  concerns,  and  it  is  improbable  that 
it  will  be  superseded  in  many  years.  The  work  is 
simply  indispensable  to  every  physician,  and  nearly 
so  to  every  liberally-educated  lawyer,  and  we 
heartily  commend  the  present  edition  to  both  pro- 
fessions.— Albany  Law  Journal,  March  26, 1881. 


By  the  Same  Author. 

The  Principles  and  Practice  of  Medical  Jurisprudence.  Third  edition. 
In  two  handsome  octavo  volumes,  containing  1416  pages,  with  188  illustrations.  Cloth,  $10 ; 
leather,  $12. 


For  years  Dr.  Taylor  was  the  highest  authority 
in  England  upon  the  subject  to  which  he  gave 
especial  attention.  His  experience  was  vast,  his 
judgment  excellent,  and  his  skill  beyond  cavil.  It 
is  therefore  well  that  the  work  of  one  who,  as  Dr. 
Stevenson  says,  had  an  "  enormous  grasp  of  all 


matters  connected  with  the  subject,"  should  be 
brought  up  to  the  present  day  and  continued  in 
its  authoritative  position.  To  accomplish  this  re- 
sult Dr.  Stevenson  has  subjected  it  to  most  careful 
editing,  bringing  it  well  up  to  the  times. — Ameri- 
can Journal  of  the  Medical  Sciences,  Jan.  1884. 


By  the  Same  Author. 

Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.    Third 

American,  from  the  third  and  revised  English  edition.     In  one  large  octavo  volume  of  788 
pages.     Cloth,  $5.50 ;  leather,  $6.50. 

PEPPEM,  AUGUSTUS  J,,  M.  S,,  M,  B.,  F.  B.  C.  S,, 

Examiner  in  Forensic  Medicine  at  the  University  of  London. 
Forensic  Medicine.    In  one  pocket-size  12mo.  volume.    Preparing.    See  StudemUf 
Series  of  Manuals,  page  4. 

LEA,  SENBY  a 

Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,  The  Ordeal  and  Torture.  Third  revised  and  enlarged  edition.  In  one 
handsome  royal  12mo.  volume  of  552  pages.     Cloth,  $2.50. 


This  valuable  work  Is  in  reality  a  history  of  civ- 
ilization as  interpreted  by  the  progress  of  jurispru- 
dence. .  .  In  "Superstition  and  Force"  we  have  a 
philosophic  survey  of  the  long  period  intervening 
between  primitive  barbarity  and  civilized  enlight- 
enment.   There  is  not  a  chapter  in  the  work  inat 


should  not  be  most  carefully  studied ;  and  however 
well  versed  the  reader  may  be  in  the  science  of 
jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of  so- 
cial science. —  Westminster  Review,  Jan.  1880. 


By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 


efit of  Clergy — Excommunication. 

octavo  volume  of  605  pages.    Cloth,  $2.50. 

The  author  is  pre-eminently  a  scholar.  He  takes 
up  every  topic  allied  with  the  leading  theme,  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  of  information 
compressed  into  the  book  is  extraordinary.  In  no 
other  single  volume  is  the  development  of  the 


New  edition.     In  one  very  handsome  royal 

♦ 

primitive  church  traced  with  so  much  clearness, 
and  with  so  definite  a  perception  of  complex  or 
conflicting  sources.  The  fifty  pages  on  the  growth 
of  the  papacy,  for  instance,  are  admirable  for  con- 
ciseness and  freedom  from  prejudice. — Boston 
Traveller,  May  3, 1883. 


Allen's  Anatomy  ....  6 

Americau  Journal  of  the  Medical  Sciences        .        3 

American  Systems  of  Gynecology  and  Obstetrics     27 

American  System  of  Practical  Medicine .  .       15 

An  American  .System  of  Dentistry  .  .       24 

Aslihurst's  Surgery       .....       20 

Ashwell  on  Diseases  of  Women       .  .  .29 

Attfleld'8  Chemistry      .         .         .    -'   .  -9 

Ball  on  the  Kectum  and  Anus  .  .  .4,20 

Barker's  Obstetrical  and  Clinical  Essays,  .       29 

Barlow's  Practice  of  Medicine         ...       17 

Barnes'  System  of  Obstetric  Medicine      .  .       29 

Bartholow  on  Klectricity        ....       17 

Bartholow's  New  Kemedies  and  their  UBes       .       11 

Basbam  on  Renal  Diseases    ....       24 

Bell's  Comparative  Physiology  and  Anatomy  .    4,   7 

Bellamy's  Surgical  Anatomy  ...        6 

Billings'  Universal  Medical  Dictionary    .  .        4 

Blandford  on  Insanity  ....       19 

Bloxam's  Chemistry      .....        9 

Bristowe's  Practice  of  Medicine     .         .         .14 

Broadbent  on  the  Pulse  .  .  .  .4,18 

Browne  on  the  Ophthalmoscope     .  .  .       23 

Browne  on  the  Throat,  Nose  and  Ear       .  .       18 

Bruce's  Materia  Medica  and  Therapeutics        .       11 

Brunton's  Materia  Medica  and  Therapeutics    .       11 

Bryant's  Practice  of  Surgery  ...  .21 

Bumstead  and  Taylor  on  Venereal.    See  Taylor.     25 

Burnett  on  the  Ear         .....       23 

Butlin  on  the  Tongue    .  .  .  .  .4,21 

Carpenter  on  the  use  and  Abuse  of  Alcohol 

Carpenter's  Human  Physiology 

Carter  &  Frost's  Ophthalmic  Surgery 

Chambers  on  Diet  and  Regimen 

Chapman's  Human  Physiology 

Charles'  Physiological  and  Pathological  Chem 

Churchill  on  Puerperal  Fever 

Clarke  and  Lockwood's  Dissectors'  Manual 

Classen's  Quantitative  Analysis 

Cleland's  Dissector        .... 

Clouston  on  Insanity    .... 

Clowes'  Practical  Chemistry 

Coats'  Pathology  .... 

Cohen  on  the  Throat     .         .    ^     • 

Coleman's  Dental  Surgery 

Condie  on  Diseases  of  Children 

Cornil  on  Syphilis  .... 

Dalton  on  the  Circulation 

Dalton's  HumanPhysiology 

Davenport  on  Diseases  ofWomen  . 

Davis'  Clinical  Lectures 

Draper's  Medical  Physics       .  .         . 

Druitfs  Modern  Surgery        .  .         . 

Duncan  on  Diseases  of  Women        .         . 

Dungllson's  Medical  Dictionary 

Edes'  Materia  Medica  and  Therapeutics 

Edis  on  Diseases  of  Women   . 

Ellis',  Demonstrations  of  Anatomy 

Emndet's  Gynaecology 

Erichsen's  System  of  Surgery 

Farquharson's  Therapeutics  and  Mat.  Med. 

Fen  wick's  Medical  Diagnosis 

rinlayson's  Clinical  Diagnosis  .  . 

Flint  on  Auscultation  and  Percussion 

Flint  on  Phthisis  .... 

Flint  on  Respiratory  Organs 

Flint  on  the  Heart        .  •    «>'   • 

Flint's  Essays       ..... 

Flint's  Practice  of  Medicine 

Folsom's  Laws  of  U.  S.  on  Custody  of  Insane 

Foster's  Physiology       .... 

Fothergill's  Handbook  of  Treatment 

Fownes'  Elementary  Chemistry     .  . 

Fox  on  Diseases  of  the  Skin  . 

Frankland  and  Japp's  Inorganic  Chemistry 

Fuller  on  the  Lungs  and  Air  Passages     . 

Gibney's  Orthopedic  Surgery 

Gould's  Surgical  Diagnosis     . 

Gray's  Anatomy     ..... 

Greene's  Medical  Chemistry  . 

Green's  Pathology  and  Morbid  Anatomy 

Grlfiath's  Universal  Formulary 

Gross  on  Foreign  Bodies  In  Air-Passages 

Gross  on  Inapof  ence  and  Sterility    . 

Gross  on  Urinary  Organs 

Gross'  System  or  Surgery 

Habershon  on  the  Abdomen 

Hamilton  on  Fractures  and  Dislocations 

Hamilton  on  Nervous  Diseases 

Hartshorne's  Anatomy  and  Physiology  . 

Hartahorne's  Conspectus  of  the  Med.  Sciences 

Hartshorne's  Essentials  of  Medicine 

Hermann's  Experimental  Pharmacology 

Hill  on  Syphilis 

HUller's  Handbook  of  Skin  Diseases 
Hoblyn'a  Medical  Dictionary 
Hodge  on  Women  .... 

Hodge's  Obstetrics        .... 
Hoflrmann  and  Power's  Chemical  Analysis 
Holden's  Landmarks   .... 
Holland's  Medical  Notes  and  Beflectlona 
Holmes'  Principles  and  Practice  of  Surgery 
Holmes'  System  of  Surgery  .  . 

Horner's  Anatomy  and  Histology  • 

Hudson  on  Fever 
Hutchinson  on  Syphilis 
Hyde  on  the  Diseases  of  the  Skin   . 


Jones  (C.  Handfleld)  on  Nervous  Disorders 
Juler's  Ophi  lialmic  Science  and  Practice 
Kinji's  Miiiiiial  01  Obstetrics  . 
Klein's  Histology  .  .  .  .    . 

Landls  on  Labor  .  .  .  . 

La  Koche  on  Pneumonia,  Malaria,  etc.    . 
La  Koclie  on  Yellow  Fever    . 
Laurence  and  Moon's  Ophthalmic  Surgery 
Lawson  on  the  Kye,  Orbit  and  Kyelld 
Lea'u  Studies  in  Church  History 
Lea's  Hupersliliou  and  Force  . 

Lee  on  Wj'philis 


4,23 
17 

8 
10 
29 
4,6 
10 

6 
19 
10 
13 
18 
24 
30 
25 

7 

8 
28 
17 

7 

20 
28 

4 
12 
27 

28 
21 
12 
16 
16 
18 
18 
18 
18 
18 
14 
19 

8 
16 

9 
26 

9 

18 

20 

4,21 

5 

9 
13 
11 
18 
25 
25 
20 

le 

22 

19 

6 

3 

14 

11 

25 

26 

4 

28 

28 

10 

5 

17 

22 

22 

6 

4 

4,25 

26 


Lehmann  s  Chemical  Physiology    . 

Lelshman's  Midwifery 

Lucas  on  Diseases  of  the  Urethra  . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fev  er  . 

Maisch's  Organic  Materia  Medica  . 

Marsh  on  the  Joints 

May  on  Diseases  of  Women   . 

Medical  News 

Medical  News  Visiting  List  . 

Medical  News  Physicians'  Ledger  . 

Meigs  on  Childbed  Fever 

Miller's  Practice  of  Surgery  .         .  . 

Miller's  Principlesof  Surgery 

Mitchell's  Nervous  Diseases  of  Women   . 

Morris  on  Diseases  of  the  Kidney  . 

NeiU  and  Smith's  Compendium  of  Med.  Scl. 

Nettleship  on  Diseases  of  the  Eye  . 

Norris  and  Oliver  on  the  Eye 

Owen  on  Diseases  of  Children 

Parrish's  Practical  Pharmacy 

Parry  on  Extra-Uterine  Pregnancy 

Parvin's  Midwifery  .... 

Pavy  on  Digestion  and  its  Disorders 

Payne's  General  Pathology    . 

Pepper's  System  of  Medicine 

Pepper's  Forensic  Medicine  . 

Pepper's  Surgical  Pathology 

Pick  on  Fractures  and  Dislocations 

Pirrie's  System  of  Surgery    . 

Play  fair  on  Nerve  Prostration  and  Hysteria 

Playfair's  Midwifery     .... 

Folitzer  on  the  Ear  and  its  Diseases 

Power's  Human  Physiology  .  .  . 

Purdy  on  Eright's  Disease  and  AUied  A  flections 

Ralfe's  Clinical  Chemistry 

Kamsbotham  on  Parturition 

Renisen's  Theoretical  Chemistry    . 

Reynolds' System  of  Medicine 

Richardson's  Preventive  Medicine 

Roberts  on  Urinary  Diseases 

Roberts'  Compend  of  Anatomy 

Roberta'  Principles  and  Practice  of  Surgery 

Robertson's  Physiological  Physics 

Ross  on  Nervous  Diseases 

Savage  on  Insanity,  including  Hysteria  . 

Schafer's  Essentials  of  Histology, 

Schreiber  on  Massage  . 

Seller  on  the  Throat.  Nose  and  Naso-Pharynx 

Senn's  Surgical  Bacteriology 

Series  of  Clinical  Manuals 

Simon's  Manual  of  Chemistry 

Slade  on  Diphtheria      .... 

Smith  (Edward)  on  Consumption   . 

Smith  (J.  Lewis)  on  Children 

Smith's  Operative  Surgery     . 

Stllle  on  Cholera  .... 

Stilie  <fe  Maisch's  National  Dispensatory 

Stillfi's  Therapeutics  and  Materia  Medica 

Stlmson  on  Fractures  and  Dislocations 

Stimson's  Operati%'e  Surgery 

Students' Series  of  Manuals  . 

Sturges'  Clinical  Medicine     .  •  • 

Tail's  Diseases  of  Women  and  Abdom.  Surgery 

Tanner  on  Signs  and  Diseases  of  Pregnancy 

Tanner's  Manual  of  Clinical  Medicine     . 

Taylor's  Atlas  of  Venereal  and  Skin  Diseases 

Taylor  on  Venereal  Diseases 

Taylor  on  Poisons  .... 

Taylor's  Medical  Jurisprudence 

Taylor's  Prin.  and  Prac.  of  Med.  Jurisprudence 

Thomas  on  Diseases  of  Women 

Thompson  on  Stricture 

Thompson  on  Urinary  Organs 

Tidy's  Legal  Medicine .  .  ■        • 

Todd  on  Acute  Diseases 

Treves' Manual  of  Surgery    . 

Treves'  Surgical  Applied  Anatomy 

Treves  on  Intestinal  Obstruction    .  . 

Tuke  on  the  Influence  of  Mind  on  the  Body  _ 

Vaughan  &  Novy's  Ptomaines  and  Leucomaines 

Visiting  List,  The  Medical  News    . 

Walshe  on  the  Heart    .  .  .         ■ 

Watson's  Practice  of  Physic  . 

Wells  on  the  Eye  .         .  .  • 

Weston  Diseases  of  Women     ,^,-.       : 

West  on  Nervous  Disorders  in  Childhood 

Williams  on  Consumption     .  .  .• 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wilson's  Human  Anatomy   .  .    ,„,•,,.,,. 

Winckel  on  Pathol,  and  Treatment  of  Childbed 

Wohler's  Organic  Chemistry 

Woodhead's  Practical  Pathology    .  .    .  ,„^ 

Year-Books  of  Treatment  for  1886, 1887  and  1889, 


19 

23 

29 

4,18 

ao 

18 
14 

23 
23 
31 
31 
25 
8 
30 
4.W 


14 
11 
4  21 
28 
1 
3 
3 
29 
21 
21 
19 
4,24 
3 
23 
23 
4,30 
11 
29 
29 
17 
13 
15 
4.31 
4.13 
4.22 
21 
19 
29 
23 
4.  8 
24 
4,10 
28 
10 
16 
17 
24 
7 
20 
4,  7 
19 
4,19 
13 
17 
18 
13 
4 
9 
18 
18 
30 
22 
16 
12 
11 
22 
22 
4 
17 
28 
29 
16 
26 
25 
31 
31 
31 
27 
24 
24 
31 
17 
21 
4,  6 
4,21 
19 
16 
3 
18 
14 
28 
28 
30 
18 
26 
6 
29 
8 
IS 
17 


liEA    BROTHERS    &   CO.,    Philadelphia. 


)r\ 


^ 


i 


I 


a^u.^  ^  /it^^^  .^^.^^^^x^  ^a^5Ca^^^^ 


/ 

^._.  v^l.2^— »^^^^— ^^-^7^^^' 


aJ, 


'Mi^C^ 


tyiyi^^\.y^^.><. 


\  \ 


